1
|
Takagi K, Akiyama E, Paternot A, Miró Ò, Charron C, Gayat E, Deye N, Cariou A, Monnet X, Jaber S, Guidet B, Damoisel C, Barthélémy R, Azoulay E, Kimmoun A, Fournier MC, Cholley B, Edwards C, Davison BA, Cotter G, Vieillard-Baron A, Mebazaa A. Early echocardiography by treating physicians and outcome in the critically ill: An ancillary study from the prospective multicenter trial FROG-ICU. J Crit Care 2022; 69:154013. [PMID: 35278876 DOI: 10.1016/j.jcrc.2022.154013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/28/2022] [Accepted: 02/15/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE This study aimed to investigate the association between the use of early echocardiography performed by the treating physician certified in critical care ultrasound and mortality in ICU patients. MATERIALS AND METHODS FROG-ICU was a multi-center cohort designed to investigate the outcome of critically ill patients. Of the 1359 patients admitted to centers where echocardiography was available, 372 patients underwent echocardiography during the initial 3 days. RESULTS Of the ICU patients admitted for cardiac disease, 47.4% underwent echocardiography, and those patients had the lowest left ventricular ejection fraction 40 [31-58] % and the lowest cardiac output 4.2 [3.2-5.7] L/min compared to patients admitted for other causes (p < 0.001 for both). One-year mortality was 36.8% and 39.9% in patients with and without echocardiography, respectively [HR 0.92 (95% CI 0.75-1.11)]. This result was confirmed after multivariable Cox regression analysis [HR 0.88 (95% CI 0.71-1.08)]. Subgroup analyses suggest that among patients admitted to ICU for cardiac disease, those managed with echocardiography had a lower risk of one-year mortality [HR 0.65 (95% CI 0.43-0.98)]. CONCLUSIONS Early echocardiography by treating physicians was not associated with short- or long-term survival in ICU patients. In subgroups, early echocardiography improved survival in ICU patients admitted for cardiac disease. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01367093.
Collapse
Affiliation(s)
- Koji Takagi
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Momentum Research, Inc., Chapel Hill, NC, USA
| | - Eiichi Akiyama
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Alexis Paternot
- Intensive Care Unit, University hospital Ambroise Paré, AP-HP, Boulogne-Billancourt, France
| | - Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona, Spain; IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Spain; Medical School, University of Barcelona, Barcelona, Spain
| | - Cyril Charron
- Intensive Care Unit, University hospital Ambroise Paré, AP-HP, Boulogne-Billancourt, France
| | - Etienne Gayat
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Department of Anesthesia and Critical Care, University Hospitals Saint-Louis-Lariboisière, DMU Parabol, FHU Promice, APHP.Nord, INI-CRCT, Paris, France
| | - Nicolas Deye
- Medical and Toxicology Intensive Care Unit, Hôpitaux Universitaires Saint Louis-Lariboisière, AP-HP, Université Paris Diderot-Paris 7, Inserm U942, Paris, France
| | - Alain Cariou
- Medical Intensive Care Unit, Cochin University Hospital, AP-HP, Université de Paris, Paris, France
| | - Xavier Monnet
- Medical Intensive Care Unit, Bicêtre Hospital, Paris-Saclay University Hospitals, Inserm UMR_S999, Paris-Suclay University, Le Kremlin-Bicetre, France
| | - Samir Jaber
- Intensive Care Unit, Anaesthesia and Critical Care Department, Saint Eloi Teaching Hospital, Centre Hospitalier, Montpellier, France
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Service de réanimation, F75012 Paris, France
| | - Charles Damoisel
- Department of Anesthesia and Critical Care, University Hospitals Saint-Louis-Lariboisière, DMU Parabol, FHU Promice, APHP.Nord, INI-CRCT, Paris, France
| | - Romain Barthélémy
- Department of Anesthesia and Critical Care, University Hospitals Saint-Louis-Lariboisière, DMU Parabol, FHU Promice, APHP.Nord, INI-CRCT, Paris, France
| | - Elie Azoulay
- Médecine Intensive et Réanimation, Hôpital Saint-Louis, AP-HP et Université de Paris, Paris, France
| | - Antoine Kimmoun
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Intensive Care Medicine Brabois, CHRU de Nancy, INSERM U1116, Université de Lorraine, 54511 Vandoeuvre-les-Nancy, France
| | - Marie-Céline Fournier
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Department of Anesthesia and Critical Care, University Hospitals Saint-Louis-Lariboisière, DMU Parabol, FHU Promice, APHP.Nord, INI-CRCT, Paris, France
| | - Bernard Cholley
- Department of Anesthesiology and Critical Care Medicine, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris, Paris, France; Inserm UMR_S 1140, Innovations Thérapeutiques en Hémostase, Paris, France
| | | | - Beth A Davison
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Momentum Research, Inc., Chapel Hill, NC, USA
| | - Gad Cotter
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Momentum Research, Inc., Chapel Hill, NC, USA
| | | | - Alexandre Mebazaa
- Inserm UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Université de Paris, Paris, France; Department of Anesthesia and Critical Care, University Hospitals Saint-Louis-Lariboisière, DMU Parabol, FHU Promice, APHP.Nord, INI-CRCT, Paris, France.
| |
Collapse
|
2
|
Liu B, Cai LD, Wang Y. Association between delayed transthoracic echocardiography and in-hospital mortality in type A acute aortic dissection-associated ST-segment elevated myocardial infarction. J Thorac Dis 2021; 13:2923-2932. [PMID: 34164183 PMCID: PMC8182513 DOI: 10.21037/jtd-20-3470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study evaluates the association between transthoracic echocardiography (TTE) timing and in-hospital mortality among individuals presenting with ST-segment elevated myocardial infarction (STEMI) complicating type A acute aortic dissection (TAAAD). Methods This cohort study obtained the data of previously published case reports from searches of PubMed (1990–2020), and adults with STEMI secondary to TAAAD were finally included. Delayed TTE (dTTE) exposure was defined as when the TTE test was made available after antithrombotic management for STEMI due to an initially missed diagnosis of TAAAD. The primary outcome of interest was in-hospital mortality, comparing individuals with dTTE and those with emergency TTE (eTTE). The odds ratio (OR) with 95% confidence interval (CI) were calculated to provide an estimate of association. Results A total of 109 individuals with a mean age of 56.7 [standard deviation (SD) 12.9] years, and of whom 75 were men (68.8%) presenting with STEMI complicating TAAAD were included. Of all patients, 68 (62.4%) had a dTTE test, which tended to be associated with increased in-hospital mortality after adjustment (OR, 2.320; 95% CI, 0.743–7.248). The association between dTTE and in-hospital death was significant only among patients presenting with a high-risk examination (HRE) (OR, 11.196; 95% CI, 1.322–94.803) and with surgical therapy (OR, 5.375; 95% CI, 1.080–26.700), and not among those presenting with negative HRE (OR, 0.150; 95% CI, 0.016–1.397) and no surgical therapy (OR, 0.177; 95% CI, 0.008–4.018). Conclusions This study found an association between dTTE and increased in-hospital mortality in TAAAD-associated STEMI patients with surgical management. This association warrants further investigation.
Collapse
Affiliation(s)
- Bei Liu
- Department of Cardiology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Li-Dong Cai
- Department of Cardiology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi Wang
- Department of Cardiology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
3
|
Malebranche D, Hasan S, Fung M, Har B, Champagne P, Schnell G, Wilton SB, Anderson TJ. Patterns of Left-Ventricular Function Assessment in Patients With Acute Coronary Syndromes. CJC Open 2021; 3:733-740. [PMID: 34169252 PMCID: PMC8209391 DOI: 10.1016/j.cjco.2020.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/31/2020] [Indexed: 12/01/2022] Open
Abstract
Background In patients with acute coronary syndromes (ACS), guidelines recommend the assessment of left-ventricular ejection fraction (LVEF). Many patients with ACS undergo multiple assessments of LVEF, the clinical value of which is unknown. Methods Patients with ACS undergoing cardiac catheterization between 2012 and 2016 were evaluated and assessments of LV function identified. To evaluate changes in LVEF over time, available echocardiograms were reviewed in a subsample of patients with LVEF data available (n = 3221). Patients with ACS were classified into 3 groups: group 1 (LVEF > 50%), group 2 (LVEF 35% to 50%), and group 3 (LVEF < 35%). Results Our cohort consisted of 8327 patients with ACS (76% men), presenting with a mean age of 62.4 ± 12.4 years. At index presentation, 66% of patients had an LVEF > 50%, 27% had an LVEF between 35% and 50%, and 7% had severely reduced LVEF of < 35%. More than half of the cohort (n = 4600) had follow-up assessment of LV function, performed over an average of 2.71 ± 1.31 years. In the subsample of 3221 patients, only 1.1% of those in group 1, and 5.1% of those in group 2, deteriorated to an LVEF < 35%. Conclusions Patients with ACS often undergo multiple assessments of LV function. Those with initially preserved EF rarely demonstrate a decline in EF to < 35%. A reduction in low-value cardiac tests may be an important first step in improving the quality of care for patients with ACS.
Collapse
Affiliation(s)
- Daniel Malebranche
- Arthur J.E. Child Fellow, Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Sarah Hasan
- Department of Cardiac Sciences and Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marinda Fung
- Department of Cardiac Sciences and Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bryan Har
- Department of Cardiac Sciences and Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Patrick Champagne
- Department of Cardiac Sciences and Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregory Schnell
- Department of Cardiac Sciences and Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen B Wilton
- Department of Cardiac Sciences and Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Todd J Anderson
- Department of Cardiac Sciences and Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
4
|
Jentzer JC, Kashou AH, Attia ZI, Lopez-Jimenez F, Kapa S, Friedman PA, Noseworthy PA. Left ventricular systolic dysfunction identification using artificial intelligence-augmented electrocardiogram in cardiac intensive care unit patients. Int J Cardiol 2020; 326:114-123. [PMID: 33152415 DOI: 10.1016/j.ijcard.2020.10.074] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/09/2020] [Accepted: 10/26/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND An artificial intelligence-augmented electrocardiogram (AI-ECG) can identify left ventricular systolic dysfunction (LVSD). We examined the accuracy of AI ECG for identification of LVSD (defined as LVEF ≤40% by transthoracic echocardiogram [TTE]) in cardiac intensive care unit (CICU) patients. METHOD We included unique Mayo Clinic CICU patients admitted from 2007 to 2018 who underwent AI-ECG and TTE within 7 days, at least one of which was during hospitalization. Discrimination of the AI-ECG for LVSD was determined using receiver-operator characteristic curve (AUC) values. RESULTS We included 5680 patients with a mean age of 68 ± 15 years (37% females). Acute coronary syndrome (ACS) was present in 55%. LVSD was present in 34% of patients (mean LVEF 48 ± 16%). The AI-ECG had an AUC of 0.83 (95% confidence interval 0.82-0.84) for discrimination of LVSD. Using the optimal cut-off, the AI-ECG had 73%, specificity 78%, negative predictive value 85% and overall accuracy 76% for LVSD. AUC values were higher for patients aged <70 years (0.85 versus 0.80), males (0.84 versus 0.79), patients without ACS (0.86 versus 0.80), and patients who did not undergo revascularization (0.84 versus 0.80). CONCLUSIONS The AI-ECG algorithm had very good discrimination for LVSD in this critically-ill CICU cohort with a high prevalence of LVSD. Performance was better in younger male patients and those without ACS, highlighting those CICU patients in whom screening for LVSD using AI ECG may be more effective. The AI-ECG might potentially be useful for identification of LVSD in resource-limited settings when TTE is unavailable.
Collapse
Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States of America.
| | - Anthony H Kashou
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Zachi I Attia
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Francisco Lopez-Jimenez
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States of America; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States of America.
| |
Collapse
|
5
|
Moores M, Yogendrakumar V, Bereznyakova O, Alesefir W, Thavorn K, Pettem H, Stotts G, Dowlatshahi D, Shamy M. Clinical Utility and Cost of Inpatient Transthoracic Echocardiography Following Acute Ischemic Stroke. Neurohospitalist 2020; 11:12-17. [PMID: 33868551 DOI: 10.1177/1941874420946513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Purpose It is unclear whether it is clinically necessary or cost-effective to routinely obtain a transthoracic echocardiogram (TTE) during inpatient admission for ischemic stroke. Methods We assessed consecutive patients presenting with acute ischemic stroke at a comprehensive stroke center from 2015 to 2017 who underwent TTE. We assessed for findings on TTE that would warrant urgent intervention including cardiac thrombus, atrial myxoma, mitral stenosis, valve vegetation, valve dysfunction requiring surgery, and low ejection fraction. Subsequent changes in management included changes in anticoagulation, antibiotics, or valve surgery. We calculated in-hospital resource utilization and associated costs for inpatient TTE using individual direct cost details within a case-costing system. Results Of 695 patients admitted with acute ischemic stroke, 516 (74%) had a TTE and were included in our analysis. TTE findings were potentially clinically significant in 30 patients (5.8%) and changed management in 17 patients (3.3%). Inpatient admission was prolonged to expedite TTE in 24 patients, while TTE occurred after discharge in 76 patients. After correcting for the cost of TTE, the mean difference in cost to prolong an admission for TTE was $555.52 (USD), or $16 832 per change in management. Conclusions Given the low clinical utility of inpatient TTE after acute ischemic stroke and the costs associated with prolonging admission, discharge from hospital should not be delayed solely to obtain TTE.
Collapse
Affiliation(s)
- Margaret Moores
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Vignan Yogendrakumar
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Olena Bereznyakova
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital and Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Walid Alesefir
- Department of Neurology, CHUM (Centre hospitalier de l'Université de Montréal), Montreal, Quebec, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Hailey Pettem
- Champlain Regional Stroke Network, Ottawa, Ontario, Canada
| | - Grant Stotts
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Michel Shamy
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
6
|
Affiliation(s)
- Vinay Kini
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| |
Collapse
|
7
|
Marturano JE, Lowery TJ. ESKAPE Pathogens in Bloodstream Infections Are Associated With Higher Cost and Mortality but Can Be Predicted Using Diagnoses Upon Admission. Open Forum Infect Dis 2019; 6:ofz503. [PMID: 31844639 PMCID: PMC6902016 DOI: 10.1093/ofid/ofz503] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 11/21/2019] [Indexed: 11/15/2022] Open
Abstract
Background ESKAPE bacteria are thought to be especially resistant to antibiotics, and their resistance and prevalence in bloodstream infections are rising. Large studies are needed to better characterize the clinical impact of these bacteria and to develop algorithms that alert clinicians when patients are at high risk of an ESKAPE infection. Methods From a US data set of >1.1 M patient encounters, we evaluated if ESKAPE pathogens produced worse outcomes than non-ESKAPE pathogens and if an ESKAPE infection could be predicted using simple word group algorithms built from decision trees. Results We found that ESKAPE pathogens represented 42.2% of species isolated from bloodstream infections and, compared with non-ESKAPE pathogens, were associated with a 3.3-day increase in length of stay, a $5500 increase in cost of care, and a 2.1% absolute increase in mortality (P < 1e-99). ESKAPE pathogens were not universally more resistant to antibiotics, but only to select antibiotics (P < 5e-6), particularly against common empiric therapies. In addition, simple word group algorithms predicted ESKAPE pathogens with a positive predictive value of 7.9% to 56.2%, exceeding 4.8% by random guessing (P < 1e-99). Conclusions Taken together, these data highlight the pathogenicity of ESKAPE bacteria, potential mechanisms of their pathogenicity, and the potential to predict ESKAPE infections upon admission. Implementing word group algorithms could enable earlier and targeted therapies against ESKAPE bacteria and thus reduce their burden on the health care system.
Collapse
|