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Gacouin A, Guillot P, Delamaire F, Le Corre A, Quelven Q, Terzi N, Tadié JM, Maamar A. Impact of cardiovascular risk factors and cardiac diseases on mortality in patients with moderate to severe ARDS: A retrospective cohort study. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 22:200318. [PMID: 39234517 PMCID: PMC11372786 DOI: 10.1016/j.ijcrp.2024.200318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 07/02/2024] [Accepted: 08/08/2024] [Indexed: 09/06/2024]
Abstract
Background History of coronary artery disease (CAD) and/or atrial fibrillation (AF) and/or valvular replacement (VR) are prevalent among patients admitted to intensive care units (ICUs). The impact of these conditions on outcomes in patients with acute respiratory distress syndrome (ARDS) remains insufficiently explored. Methods We performed a retrospective study on prospectively collected data from patients with ARDS and a PaO2/FiO2 ratio ≤150 mmHg. Patients were admitted between January 2006 and March 2022. We used multivariable logistic regression analysis. The primary outcome was 1-year mortality from admission to the ICU; secondary outcomes included mortality at 28 days and 90 days. Results Among 1.033 patients, 181 (17.5 %) had a history of CAD and/or AF and/or VR. History of CAD and/or AF and/or VR was independently associated with 1-year mortality (Odds-Ratio (OR) = 2.59, 95 % confidence interval (CI) 1.76-3.82, p < 0.001), with mortality at 90 days (OR = 1.87, 95 % CI 1.27-2.76, p = 0.001), but not with mortality at 28 days (OR = 1.40, 95 % CI 0.93-2.11, p = 0.10). In sensitivity analyses, history of CAD and/or AF and/or VR remained independently associated with 1-year mortality in ICU survivors (OR = 3.58, 95 % CI = 2.41-7.82, p < 0.001). Conclusions History of CAD and/or AF and/or VR was associated with mortality in ARDS. Prompt referral to cardiologists for comprehensive management post-ICU discharge may be warranted to optimize outcomes in this vulnerable population.
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Affiliation(s)
- Arnaud Gacouin
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France
- Université Rennes 1, Faculté de Médecine, Biosit, F-35043 Rennes, France
- Inserm-CIC-1414, Faculté de Médecine, Université Rennes 1, IFR 140, F-35033 Rennes, France
| | - Pauline Guillot
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France
- Université Rennes 1, Faculté de Médecine, Biosit, F-35043 Rennes, France
| | - Flora Delamaire
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France
- Université Rennes 1, Faculté de Médecine, Biosit, F-35043 Rennes, France
| | - Alexia Le Corre
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France
- Université Rennes 1, Faculté de Médecine, Biosit, F-35043 Rennes, France
| | - Quentin Quelven
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France
- Université Rennes 1, Faculté de Médecine, Biosit, F-35043 Rennes, France
| | - Nicolas Terzi
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France
- Université Rennes 1, Faculté de Médecine, Biosit, F-35043 Rennes, France
- Inserm-CIC-1414, Faculté de Médecine, Université Rennes 1, IFR 140, F-35033 Rennes, France
| | - Jean Marc Tadié
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France
- Université Rennes 1, Faculté de Médecine, Biosit, F-35043 Rennes, France
- Inserm-CIC-1414, Faculté de Médecine, Université Rennes 1, IFR 140, F-35033 Rennes, France
| | - Adel Maamar
- CHU Rennes, Maladies Infectieuses et Réanimation Médicale, F-35033 Rennes, France
- Université Rennes 1, Faculté de Médecine, Biosit, F-35043 Rennes, France
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Miller PE, Huber K, Bohula EA, Krychtiuk KA, Pöss J, Roswell RO, Tavazzi G, Solomon MA, Kristensen SD, Morrow DA. Research Priorities in Critical Care Cardiology: JACC Expert Panel. J Am Coll Cardiol 2023; 82:2329-2337. [PMID: 38057075 PMCID: PMC10752230 DOI: 10.1016/j.jacc.2023.09.828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/15/2023] [Accepted: 09/20/2023] [Indexed: 12/08/2023]
Abstract
Over the last several decades, the cardiac intensive care unit (CICU) has seen a substantial evolution in the patient population, comorbidities, and diagnoses. However, the generation of high-quality evidence to manage these complex and critically ill patients has been slow. Given the scarcity of clinical trials focused on critical care cardiology (CCC), CICU clinicians are often left to extrapolate from studies that either exclude or poorly represent the patient population admitted to CICUs. The lack of high-quality evidence and limited guidance from society guidelines has led to significant variation in practice patterns for many of the most common CICU diagnoses. Several barriers, both common to critical care research and unique to CCC, have impeded progress. In this multinational perspective, we describe key areas of priority for CCC research, current challenges for investigation in the CICU, and essential elements of a path forward for the field.
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Affiliation(s)
- P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Konstantin A Krychtiuk
- Department of Internal Medicine II, Division of Cardiology Medical University of Vienna, Vienna, Austria; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Janine Pöss
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Robert O Roswell
- Northwell Health, Zucker School of Medicine, Hempstead, New York, USA
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Intensive Care Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - 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
| | | | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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3
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Metkus TS. Trials and Tribulations of Inotrope Choice in Cardiogenic Shock With Renal Dysfunction. JACC. ADVANCES 2023; 2:100392. [PMID: 38361971 PMCID: PMC10867817 DOI: 10.1016/j.jacadv.2023.100392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
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
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4
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Metkus TS, Baird-Zars VM, Alfonso CE, Alviar CL, Barnett CF, Barsness GW, Berg DD, Bertic M, Bohula EA, Burke J, Burstein B, Chaudhry SP, Cooper HA, Daniels LB, Fordyce CB, Ghafghazi S, Goldfarb M, Katz JN, Keeley EC, Keller NM, Kenigsberg B, Kontos MC, Kwon Y, Lawler PR, Leibner E, Liu S, Menon V, Miller PE, Newby LK, O'Brien CG, Papolos AI, Pierce MJ, Prasad R, Pisani B, Potter BJ, Roswell RO, Sinha SS, Shah KS, Smith TD, Snell RJ, So D, Solomon MA, Ternus BW, Teuteberg JJ, van Diepen S, Zakaria S, Morrow DA. Critical Care Cardiology Trials Network (CCCTN): a cohort profile. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:703-708. [PMID: 36029517 PMCID: PMC9603535 DOI: 10.1093/ehjqcco/qcac055] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/12/2022]
Abstract
AIMS The aims of the Critical Care Cardiology Trials Network (CCCTN) are to develop a registry to investigate the epidemiology of cardiac critical illness and to establish a multicentre research network to conduct randomised clinical trials (RCTs) in patients with cardiac critical illness. METHODS AND RESULTS The CCCTN was founded in 2017 with 16 centres and has grown to a research network of over 40 academic and clinical centres in the United States and Canada. Each centre enters data for consecutive cardiac intensive care unit (CICU) admissions for at least 2 months of each calendar year. More than 20 000 unique CICU admissions are now included in the CCCTN Registry. To date, scientific observations from the CCCTN Registry include description of variations in care, the epidemiology and outcomes of all CICU patients, as well as subsets of patients with specific disease states, such as shock, heart failure, renal dysfunction, and respiratory failure. The CCCTN has also characterised utilization patterns, including use of mechanical circulatory support in response to changes in the heart transplantation allocation system, and the use and impact of multidisciplinary shock teams. Over years of multicentre collaboration, the CCCTN has established a robust research network to facilitate multicentre registry-based randomised trials in patients with cardiac critical illness. CONCLUSION The CCCTN is a large, prospective registry dedicated to describing processes-of-care and expanding clinical knowledge in cardiac critical illness. The CCCTN will serve as an investigational platform from which to conduct randomised controlled trials in this important patient population.
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Affiliation(s)
- Thomas S Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Carlos E Alfonso
- Division of Cardiology, Department of Medicine; University of Miami Hospital & Clinics, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Carlos L Alviar
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York 10016 NY, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55902, USA
| | - David D Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Mia Bertic
- University of Toronto Etobicoke,Toronto ON, Canada
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - James Burke
- Lehigh Valley Heart Institute, Allentown, PA 18103, USA
| | | | | | - Howard A Cooper
- Westchester Medical Center and New York Medical College, Valhalla NY 10901, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine La Jolla, UCSD, San Diego, CA 92037, USA
| | - Christopher B Fordyce
- UBC Centre for Cardiovascular Innovation, Cardiovascular Health Program, UBC Centre for Health Evaluation & Outcomes Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Shahab Ghafghazi
- Division of Cardiovascular Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montréal, QC, Canada
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Ellen C Keeley
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Norma M Keller
- Department of Medicine at NYU Grossman School of Medicine, Bellevue Hospital, New York NY 10016, USA
| | - Benjamin Kenigsberg
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington DC, WA 20010, USA
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA 23219, USA
| | - Younghoon Kwon
- Division of Cardiology, University of Washington, Seattle, WA 98104, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto ON, Canada
| | - Evan Leibner
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, NY 10029, USA
| | - Shuangbo Liu
- Max Rady College of Medicine St. Boniface Hospital Winnipeg, Manitoba, Canada
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT 06510, USA
| | - L Kristin Newby
- Divison of Cardiology, Duke University School of Medicine, Durham, NC 27710, USA
| | - Connor G O'Brien
- Department of Medicine, Division of Cardiology, University of California-San Francisco School of Medicine, San Francisco, CA 94143, USA
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington DC, WA 20010, USA
| | - Matthew J Pierce
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, Long Island, NY 11549, USA
| | - Rajnish Prasad
- Wellstar Cardiovascular Medicine, Marietta, GA 30060, USA
| | | | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA 22042, USA
| | - Kevin S Shah
- University of Utah Health Sciences Center, Salt Lake City, UT 84132, USA
| | - Timothy D Smith
- The Christ Hospital and Lindner Institute for Research and Education Cincinnati, OH 45219, USA
| | | | - Derek So
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | | | - Bradley W Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, WI 53792, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University Medical Center, Palo Alto, CA 94305, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
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ICU Versus High-Dependency Care Unit for Patients With Acute Myocardial Infarction: A Nationwide Propensity Score-Matched Cohort Study. Crit Care Med 2022; 50:977-985. [PMID: 35020671 DOI: 10.1097/ccm.0000000000005440] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To compare the outcomes of patients with acute myocardial infarction who were treated in ICUs versus high-dependency care units (HDUs). DESIGN A nationwide, propensity score-matched, retrospective cohort study of a national administrative inpatient database in Japan from July 2010 to March 2018. SETTING Six hundred sixty-six acute-care hospitals with ICU and/or HDU beds covering about 75% of all ICU beds and 70% of all HDU beds in Japan. PATIENTS Adult patients who were hospitalized for acute myocardial infarction and admitted to the ICU or HDU on the day of hospital admission. Propensity score-matching analysis was performed to compare the inhospital mortality between patients treated in the ICU and HDU on the day of hospital admission. INTERVENTIONS ICU or HDU admission on the day of hospital admission. MEASUREMENTS AND MAIN RESULTS Of 135,142 eligible patients, 89,382 (66%) were admitted to the ICU and 45,760 (34%) were admitted to the HDU on the day of admission. After propensity score matching, there was no statistically significant difference in inhospital mortality between the ICU and HDU groups (5.0% vs 5.5%; difference, -0.5%; 95% CI, -1.0% to 0.1%). In the subgroup analyses, inhospital mortality was significantly lower in the ICU group than that in the HDU group among patients with Killip class IV (25.6% vs 28.4%; difference, -2.9%; 95% CI, -5.4% to -0.3%), patients who underwent intubation (40.0% vs 46.6%; difference, -6.6%; 95% CI, -10.6% to -2.7%), and patients who received mechanical circulatory support (21.8% vs 24.7%; difference, -2.8%; 95% CI, -5.5% to -0.2%). CONCLUSIONS Critical care in the ICU compared with that in the HDU was not associated with reduced inhospital mortality among the entire cohort of patients with acute myocardial infarction but was associated with reduced inhospital mortality among the subsets of patients with Killip class IV, intubation, or mechanical circulatory support.
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Challenges in the conduct of randomised controlled trials in cardiogenic shock complicating acute myocardial infarction. J Geriatr Cardiol 2022; 19:125-129. [PMID: 35317398 PMCID: PMC8915423 DOI: 10.11909/j.issn.1671-5411.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cardiogenic shock (CS) following acute myocardial infarction (AMI) is a major challenge in cardiovascular care. Mortality remains high with 40%-50% after thirty days. Randomised controlled trials (RCTs) play a key role to generate evidence on optimal care in this field. However, the number of completed or ongoing RCTs is still relatively low compared to the gaps in evidence. Challenges in the conduct of these trials are in particular the selection of patients and ethical issues in the informed consent process. When determining eligibility criteria, special attention should be paid to the severity of CS, to the inclusion of patients with cardiac arrest and to potential age limits. Median age of AMI-CS patients is increasing. Age limits are therefore controversial as it is important to include elderly patients in RCTs in order to make the results generalisable and to address the special needs of this group. As patients with AMI-CS are in most cases unable to provide informed consent themselves, a step-wise approach with acute consent by a legal representative or independent physicians and later informed consent by the patient if possible might be established depending on regularities of the respective ethical review board and country legislation. Multicenter studies should be sought to generate adequate power.
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Ohbe H, Matsui H, Yasunaga H. Intensive care unit versus high-dependency care unit for patients with acute heart failure: a nationwide propensity score-matched cohort study. J Intensive Care 2021; 9:78. [PMID: 34930470 PMCID: PMC8686245 DOI: 10.1186/s40560-021-00592-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/10/2021] [Indexed: 12/28/2022] Open
Abstract
Background A structure and staffing model similar to that in general intensive care unit (ICUs) is applied to cardiac intensive care unit (CICUs) for patients with acute heart failure. However, there is limited evidence on the structure and staffing model of CICUs. The present study aimed to assess whether critical care for patients with acute heart failure in the ICUs is associated with improved outcomes than care in the high-dependency care units (HDUs), the hospital units in which patient care levels and costs are between the levels found in the ICU and general ward. Methods This nationwide, propensity score-matched, retrospective cohort study was performed using a national administrative inpatient database in Japan. We identified all patients who were hospitalized for acute heart failure and admitted to the ICU or HDU on the day of hospital admission from April 2014 to March 2019. Propensity score-matching analysis was performed to compare the in-hospital mortality between acute heart failure patients treated in the ICU and HDU on the day of hospital admission. Results Of 202,866 eligible patients, 78,646 (39%) and 124,220 (61%) were admitted to the ICU and HDU, respectively, on the day of admission. After propensity score matching, there was no statistically significant difference in in-hospital mortality between patients who were admitted to the ICU and HDU on the day of admission (10.7% vs. 11.4%; difference, − 0.6%; 95% confidence interval, − 1.5% to 0.2%). In the subgroup analyses, there was a statistically significant difference in in-hospital mortality between the ICU and HDU groups among patients receiving noninvasive ventilation (9.4% vs. 10.5%; difference, − 1.0%; 95% confidence interval, − 1.9% to − 0.1%) and patients receiving intubation (32.5% vs. 40.6%; difference, − 8.0%; 95% confidence interval, − 14.5% to − 1.5%). There were no statistically significant differences in other subgroup analyses. Conclusions Critical care in ICUs was not associated with lower in-hospital mortality than critical care in HDUs among patients with acute heart failure. However, critical care in ICUs was associated with lower in-hospital mortality than critical care in HDUs among patients receiving noninvasive ventilation and intubation. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-021-00592-2.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan.
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 1130033, Japan
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Metkus TS, Stephens RS, Schulman S, Hsu S, Morrow DA, Eid SM. Utilization and outcomes of early respiratory support in 6.5 million acute heart failure hospitalizations. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 6:72-80. [PMID: 31225598 DOI: 10.1093/ehjqcco/qcz030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/09/2019] [Accepted: 06/13/2019] [Indexed: 12/19/2022]
Abstract
AIMS The incidence and outcomes of a requirement for non-invasive ventilation (NIV) or invasive mechanical ventilation (IMV) in acute heart failure (AHF) hospitalization are not clearly established. Thus, we aimed to characterize the incidence and trends in use of IMV and NIV in AHF and to estimate the magnitude of hazard for mortality associated with requiring IMV and NIV in AHF. METHODS AND RESULTS We used the National Inpatient Sample (NIS) to identify AHF hospitalizations between 2008 and 2014. The exposure variable of interest was IMV or NIV use within 24 h of hospital admission compared to no respiratory support. We analysed the association between ventilation strategies and in-hospital mortality using Cox proportional hazards models adjusting for demographics and comorbidities. We included 6 534 675 hospitalizations for AHF. Of these, 271 589 (4.16%) included NIV and 51 459 (0.79%) included IMV within the first 24 h of hospitalization and rates of NIV and IMV use increased over time. In-hospital mortality for AHF hospitalizations including NIV was 5.0% and 27% for IMV compared with 2.1% for neither (P < 0.001 for both). In an adjusted model, requirement for NIV was associated with over two-fold higher risk for in-hospital mortality [hazard ratio (HR) 2.10, 95% confidence interval (CI) 2.01-2.19; P < 0.001] and requirement for IMV was associated with over three-fold higher risk for in-hospital mortality (HR 3.39, 95% CI 3.14-3.66; P < 0.001). CONCLUSION Respiratory support is used in many AHF hospitalizations, and AHF patients who require respiratory support are at high risk for in-hospital mortality. Our work should inform prospective intervention trials and quality improvement ventures in this high-risk population.
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Affiliation(s)
- Thomas S Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Blalock 524, D2, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Robert Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Steven Schulman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Blalock 524, D2, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Steven Hsu
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Blalock 524, D2, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Shaker M Eid
- Department of Medicine, Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, MD 21224, USA
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Metkus T, Miller PE, Alviar CL, Jentzer JC, van Diepen S, Katz JN, Morrow DA, Schulman S, Eid S. Incidence, predictors and prognosis of respiratory support in non-ST segment elevation myocardial infarction. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:200–206. [PMID: 32324057 DOI: 10.1177/2048872620919947] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/26/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND The incidences of invasive mechanical ventilation and non-invasive ventilation among patients with non-ST segment elevation myocardial infarction and associated prognosis are not well characterized. METHODS We conducted a retrospective cohort study of patients with admission diagnosis of non-ST segment elevation myocardial infarction using the US National Inpatient Sample database between 2002-2014. The exposure variable was invasive mechanical ventilation or non-invasive ventilation within 24 h of admission, compared to no respiratory support. The primary outcome was in-hospital mortality. We determined the association between respiratory support and mortality using Cox proportional hazard models. RESULTS A total of 4,152,421 non-ST segment elevation myocardial infarction hospitalizations were identified, among whom 1.3% required non-invasive ventilation and 1.9% required invasive mechanical ventilation. Non-invasive ventilation use increased over time (0.4% in 2002 to 2.4% in 2014, p<0.001) while there was no definite trend in invasive mechanical ventilation use. Revascularization was lower for non-ST segment elevation myocardial infarction hospitalizations including invasive mechanical ventilation (23.9%) and non-invasive ventilation (14.5%) compared to 36.5% of those without respiratory support (p<0.001). In-hospital mortality was 3.1% for non-ST segment elevation myocardial infarction without respiratory support compared to 9.2% with non-invasive ventilation (adjusted hazard ratio 1.86, 95% confidence interval 1.74-1.98) and 37.2% with invasive mechanical ventilation (adjusted hazard ratio 3.03, 95% confidence interval 2.88-3.19). Mortality for non-ST segment elevation myocardial infarction-non-invasive ventilation is improving over time while mortality for non-ST segment elevation myocardial infarction-invasive mechanical ventilation is increasing over time. CONCLUSION Mechanical respiratory support in non-ST segment elevation myocardial infarction is used in an important minority of cases, is increasing and is independently associated with mortality. Studies of the optimal management of acute coronary syndrome complicated by respiratory failure are needed to improve outcomes.
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Affiliation(s)
- Thomas Metkus
- Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, USA
| | - Carlos L Alviar
- Leon H. Charney Division of Cardiology, New York University School of Medicine, USA
| | | | - Sean van Diepen
- Department of Critical Care and Division of Cardiology and Department of Medicine, University of Alberta Canada
| | - Jason N Katz
- Division of Cardiology, Duke University, Durham, NC USA
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven Schulman
- Department of Medicine, Johns Hopkins University School of Medicine, USA
| | - Shaker Eid
- Department of Medicine, Johns Hopkins University School of Medicine, USA
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Abstract
Supplemental Digital Content is available in the text. The medical complexity and critical care needs of patients admitted to cardiac ICUs are increasing, and prospective studies examining the underlying cardiac and noncardiac diagnoses, the management strategies, and the prognosis of cardiac ICU patients with respiratory failure are needed.
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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: 149] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [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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12
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Nonogi H. The necessity of conversion from coronary care unit to the cardiovascular intensive care unit required for cardiologists. J Cardiol 2018; 73:120-125. [PMID: 30342787 DOI: 10.1016/j.jjcc.2018.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 09/18/2018] [Indexed: 12/22/2022]
Abstract
The in-hospital mortality rate of acute myocardial infarction (AMI) has dramatically decreased due to the treatment at the coronary care unit (CCU), especially with the progress of arrhythmia therapy and reperfusion therapy. On the other hand, severe heart failure and multiple organ failure are increasing due to aging populations and multiple organ diseases. As a result, patients with AMI without complications are less likely to be admitted to the CCU, and cardiologists staying in the CCU have also decreased. The mortality rate is high when complications such as cardiogenic shock, cardiac rupture, and in-hospital cardiac arrest occur in AMI, therefore careful intensive care even in low-risk AMI is necessary. For cardiologists, mechanical ventilation, renal replacement therapy, or infection control are necessary for cardiovascular intensive care, and integrated multidisciplinary care coordinated by skilled intensive care physicians, nurses, respiratory therapists, physiotherapists, pharmacists, nutritionists, social workers, and clinical engineers is important. Therefore, for the critical care of cardiovascular diseases, it is necessary to convert from CCU to the cardiovascular intensive care unit.
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Affiliation(s)
- Hiroshi Nonogi
- Intensive Care Center, Shizuoka General Hospital, Shizuoka, Japan.
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Morrow DA. Evidence-Based Redesign of the Cardiac Intensive Care Unit. J Am Coll Cardiol 2018; 68:2649-2651. [PMID: 27978949 DOI: 10.1016/j.jacc.2016.10.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Affiliation(s)
- David A Morrow
- Samuel A. Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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14
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Watson RA, Bohula EA, Gilliland TC, Sanchez PA, Berg DD, Morrow DA. Editor’s Choice-Prospective registry of cardiac critical illness in a modern tertiary care Cardiac Intensive Care Unit. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:755-761. [DOI: 10.1177/2048872618789053] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The changing landscape of care in the Cardiac Intensive Care Unit (CICU) has prompted efforts to redesign the structure and organization of advanced CICUs. Few studies have quantitatively characterized current demographics, diagnoses, and outcomes in the contemporary CICU. Methods: We evaluated patients in a prospective observational database, created to support quality improvement and clinical care redesign in an AHA Level 1 (advanced) CICU at Brigham and Women’s Hospital, Boston, MA, USA. All consecutive patients ( N=2193) admitted from 1 January 2015 to 31 December 2017 were included at the time of admission to the CICU. Results: The median age was 65 years (43% >70 years) and 44% of patients were women. Non-cardiovascular comorbidities were common, including chronic kidney disease (27%), pulmonary disease (22%), and active cancer (13%). Only 7% of CICU admissions were primarily for an acute coronary syndrome, which was the seventh most common individual diagnosis. The top three reasons for admission to the CICU were shock/hypotension (26%), cardiopulmonary arrest (11%), or primary arrhythmia without arrest (9%). Respiratory failure was a primary or major secondary reason for triage to the CICU in 17%. In-hospital mortality was 17.6%. Conclusions: In a tertiary, academic, advanced CICU, patients are elderly with a high burden of non-cardiovascular comorbid conditions. Care has shifted from ACS toward predominantly shock and cardiac arrest, as well as non-ischemic conditions, and the mortality of these conditions is high. These data may be useful to guide cardiac critical care redesign.
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Affiliation(s)
- Ryan A Watson
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Erin A Bohula
- Heart and Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Thomas C Gilliland
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - Pablo A Sanchez
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - David D Berg
- Deparment of Medicine, Division of Cardiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
| | - David A Morrow
- Heart and Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
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Metkus TS, Albaeni A, Chandra-Strobos N, Eid SM. Incidence and Prognostic Impact of Respiratory Support in Patients With ST-Segment Elevation Myocardial Infarction. Am J Cardiol 2017; 119:171-177. [PMID: 27956004 DOI: 10.1016/j.amjcard.2016.09.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/23/2016] [Accepted: 09/23/2016] [Indexed: 11/29/2022]
Abstract
Data addressing the use of respiratory support in acute coronary syndromes are lacking. To address this evidence gap, we characterized prognostic impact and trends in utilization of invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV) in patients hospitalized with ST-segment elevation myocardial infarction (STEMI) from 2002 through 2013 using the National Inpatient Sample. Multivariate logistic regression was performed to identify patient, hospital, and clinical characteristics associated with requiring IMV or NIV within 24 hours of hospitalization. Multivariate Cox proportional hazards regression was used to quantify the magnitude of in-hospital mortality associated with IMV and NIV use. From 2002 to 2013, we identified 1,867,114 patients with STEMI. Age, gender, higher co-morbidity burden, and chronic pulmonary disease were significantly associated with need for respiratory support. The use of IMV and NIV increased at average annual rates of 6.6% and 14.3%, respectively (ptrend <0.001). Age- and gender-adjusted mortality rates are high but declined for patients with STEMI requiring IMV (44.7% in 2002 to 37.6% in 2013, ptrend = 0.002) and NIV (11.6% in 2002 to 6.8% in 2013, ptrend <0.001). Compared to patients with STEMI with no ventilation need, a requirement for IMV or NIV was associated with increased adjusted in-hospital mortality (hazard ratio 2.5, p <0.001 and 1.7, p <0.001, respectively). In conclusion, approximately 1 in 23 patients hospitalized with STEMI will require respiratory support in the form of IMV or NIV. Patients with STEMI who require respiratory support have a high risk of death, although rates of in-hospital mortality have decreased over time.
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Affiliation(s)
- Thomas S Metkus
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Aiham Albaeni
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nisha Chandra-Strobos
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shaker M Eid
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Katz JN, Minder M, Olenchock B, Price S, Goldfarb M, Washam JB, Barnett CF, Newby LK, van Diepen S. The Genesis, Maturation, and Future of Critical Care Cardiology. J Am Coll Cardiol 2016; 68:67-79. [DOI: 10.1016/j.jacc.2016.04.036] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 04/18/2016] [Accepted: 04/19/2016] [Indexed: 12/29/2022]
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Is it time to reprioritize our research focus in critical care medicine? A call for more collaboration between cardiologists and intensive care specialists. Crit Care Med 2015; 43:247-8. [PMID: 25514718 DOI: 10.1097/ccm.0000000000000653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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