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Sinha SS, Bohula EA, Diepen SVAN, Leonardi S, Mebazaa A, Proudfoot AG, Sionis A, Chia YW, Zampieri FG, Lopes RD, Katz JN. The Intersection Between Heart Failure and Critical Care Cardiology: An International Perspective on Structure, Staffing, and Design Considerations. J Card Fail 2022; 28:1703-1716. [PMID: 35843489 DOI: 10.1016/j.cardfail.2022.06.007] [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: 06/09/2021] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
The overall patient population in contemporary cardiac intensive care units (CICUs) has only increased with respect to patient acuity, complexity, and illness severity. The current population has more cardiac and noncardiac comorbidities, a higher prevalence of multiorgan injury, and consumes more critical care resources than previously. Patients with heart failure (HF) now occupy a large portion of contemporary tertiary or quaternary care CICU beds around the world. In this review, we discuss the core issues that relate to the care of critically ill patients with HF, including global perspectives on the organization, designation, and collaboration of CICUs regionally and across institutions, as well as unique models for provisioning care for patients with HF within a health care setting. The latter includes a discussion of traditional and emerging models, specialized HF units, the makeup and implementation of multidisciplinary team-based decision-making, and cardiac critical care admission and triage practices. This article illustrates the ways in which critically ill patients with HF have helped to shape contemporary CICUs throughout the world and explores how these very patients will similarly help to inform the future maturation of these specialized critical care units. Finally, we will critically examine broad, contemporary, international models of HF and cardiac critical care delivery in North America, Europe, South America, and Asia, and conclude with opportunities for the further investigation and generation of evidence for care delivery.
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Affiliation(s)
- Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - 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
| | - Sean VAN Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sergio Leonardi
- Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Pavia, Italy
| | - Alexandre Mebazaa
- Université de Paris, Inserm 942 MASCOT, APHP Hôpitaux Universitaires Saint-Louis-Lariboisière, Paris, France
| | - Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, UK; Clinic For Anaesthesiology & Intensive Care, Charité-Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Univesität zu, Berlin, Germany
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Yew Woon Chia
- Cardiac Intensive Care Unit, Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Fernando G Zampieri
- HCor Research Institute, São Paulo, Brazil Intensive Care Unit, Federal University of São Paulo, Brazil
| | - Renato D Lopes
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina; Brazilian Clinical Research Institute (BCRI), Sao Paulo, Brazil
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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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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Sinha SS, Sjoding MW, Sukul D, Prescott HC, Iwashyna TJ, Gurm HS, Cooke CR, Nallamothu BK. Changes in Primary Noncardiac Diagnoses Over Time Among Elderly Cardiac Intensive Care Unit Patients in the United States. Circ Cardiovasc Qual Outcomes 2018; 10:e003616. [PMID: 28794121 DOI: 10.1161/circoutcomes.117.003616] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/31/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Early reports suggest the number of cardiac intensive care unit (CICU) patients with primary noncardiac diagnoses is rising in the United States, but no national data currently exist. We examined changes in primary noncardiac diagnoses among elderly patients admitted to a CICU during the past decade. METHODS AND RESULTS Using 2003 to 2013 Medicare data, we grouped elderly patients admitted to CICUs into 2 categories based on principal diagnosis at discharge: (1) primary noncardiac diagnoses and (2) primary cardiac diagnoses. We examined changes in patient demographics, comorbidities, procedure use, and risk-adjusted in-hospital mortality. Among 3.4 million admissions with a CICU stay, primary noncardiac diagnoses rose in prevalence from 38.0% to 51.7% between 2003 and 2013. The fastest rising primary noncardiac diagnoses were infectious diseases (7.8%-15.1%) and respiratory diseases (6.0%-7.6%; P<0.001 for both), whereas the fastest declining primary cardiac diagnosis was coronary artery disease (32.3%-19.0%; P<0.001). Simultaneously, the prevalence of both cardiovascular and noncardiovascular comorbidities rose: heart failure (13.9%-34.4%), pulmonary vascular disease (1.2%-7.1%), valvular heart disease (5.0%-9.8%), and renal failure (7.1%-19.6%; P<0.001 for all). As compared with those with primary cardiac diagnoses, elderly CICU patients with primary noncardiac diagnoses had higher rates of noncardiac procedure use and risk-adjusted in-hospital mortality (P<0.001 for all). Risk-adjusted in-hospital mortality declined slightly in the overall cohort from 9.3% to 8.9% (P<0.001). CONCLUSIONS More than half of all elderly patients with a CICU stay across the United States now have primary noncardiac diagnoses at discharge. These patients receive different types of care and have worse outcomes than patients with primary cardiac diagnoses. Our work has important implications for the development of appropriate training and staffing models for the future critical care workforce.
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Affiliation(s)
- Shashank S Sinha
- From the Division of Cardiovascular Medicine, Samuel and Jean Frankel Cardiovascular Center (S.S.S., D.S., H.S.G., B.K.N.), Division of Pulmonary and Critical Care Medicine (M.W.S., H.C.P., T.J.I., C.R.C.), Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation (S.S.S., M.W.S., H.C.P., T.J.I., B.K.N.), and Michigan Center for Integrative Research in Critical Care (S.S.S., M.W.S., H.C.P., T.J.I., C.R.C., B.K.N.), University of Michigan, Ann Arbor; and Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, MI (H.C.P., T.J.I., H.S.G., B.K.N.).
| | - Michael W Sjoding
- From the Division of Cardiovascular Medicine, Samuel and Jean Frankel Cardiovascular Center (S.S.S., D.S., H.S.G., B.K.N.), Division of Pulmonary and Critical Care Medicine (M.W.S., H.C.P., T.J.I., C.R.C.), Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation (S.S.S., M.W.S., H.C.P., T.J.I., B.K.N.), and Michigan Center for Integrative Research in Critical Care (S.S.S., M.W.S., H.C.P., T.J.I., C.R.C., B.K.N.), University of Michigan, Ann Arbor; and Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, MI (H.C.P., T.J.I., H.S.G., B.K.N.)
| | - Devraj Sukul
- From the Division of Cardiovascular Medicine, Samuel and Jean Frankel Cardiovascular Center (S.S.S., D.S., H.S.G., B.K.N.), Division of Pulmonary and Critical Care Medicine (M.W.S., H.C.P., T.J.I., C.R.C.), Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation (S.S.S., M.W.S., H.C.P., T.J.I., B.K.N.), and Michigan Center for Integrative Research in Critical Care (S.S.S., M.W.S., H.C.P., T.J.I., C.R.C., B.K.N.), University of Michigan, Ann Arbor; and Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, MI (H.C.P., T.J.I., H.S.G., B.K.N.)
| | - Hallie C Prescott
- From the Division of Cardiovascular Medicine, Samuel and Jean Frankel Cardiovascular Center (S.S.S., D.S., H.S.G., B.K.N.), Division of Pulmonary and Critical Care Medicine (M.W.S., H.C.P., T.J.I., C.R.C.), Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation (S.S.S., M.W.S., H.C.P., T.J.I., B.K.N.), and Michigan Center for Integrative Research in Critical Care (S.S.S., M.W.S., H.C.P., T.J.I., C.R.C., B.K.N.), University of Michigan, Ann Arbor; and Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, MI (H.C.P., T.J.I., H.S.G., B.K.N.)
| | - Theodore J Iwashyna
- From the Division of Cardiovascular Medicine, Samuel and Jean Frankel Cardiovascular Center (S.S.S., D.S., H.S.G., B.K.N.), Division of Pulmonary and Critical Care Medicine (M.W.S., H.C.P., T.J.I., C.R.C.), Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation (S.S.S., M.W.S., H.C.P., T.J.I., B.K.N.), and Michigan Center for Integrative Research in Critical Care (S.S.S., M.W.S., H.C.P., T.J.I., C.R.C., B.K.N.), University of Michigan, Ann Arbor; and Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, MI (H.C.P., T.J.I., H.S.G., B.K.N.)
| | - Hitinder S Gurm
- From the Division of Cardiovascular Medicine, Samuel and Jean Frankel Cardiovascular Center (S.S.S., D.S., H.S.G., B.K.N.), Division of Pulmonary and Critical Care Medicine (M.W.S., H.C.P., T.J.I., C.R.C.), Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation (S.S.S., M.W.S., H.C.P., T.J.I., B.K.N.), and Michigan Center for Integrative Research in Critical Care (S.S.S., M.W.S., H.C.P., T.J.I., C.R.C., B.K.N.), University of Michigan, Ann Arbor; and Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, MI (H.C.P., T.J.I., H.S.G., B.K.N.)
| | - Colin R Cooke
- From the Division of Cardiovascular Medicine, Samuel and Jean Frankel Cardiovascular Center (S.S.S., D.S., H.S.G., B.K.N.), Division of Pulmonary and Critical Care Medicine (M.W.S., H.C.P., T.J.I., C.R.C.), Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation (S.S.S., M.W.S., H.C.P., T.J.I., B.K.N.), and Michigan Center for Integrative Research in Critical Care (S.S.S., M.W.S., H.C.P., T.J.I., C.R.C., B.K.N.), University of Michigan, Ann Arbor; and Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, MI (H.C.P., T.J.I., H.S.G., B.K.N.)
| | - Brahmajee K Nallamothu
- From the Division of Cardiovascular Medicine, Samuel and Jean Frankel Cardiovascular Center (S.S.S., D.S., H.S.G., B.K.N.), Division of Pulmonary and Critical Care Medicine (M.W.S., H.C.P., T.J.I., C.R.C.), Michigan Integrated Center for Health Analytics and Medical Prediction, Institute for Healthcare Policy and Innovation (S.S.S., M.W.S., H.C.P., T.J.I., B.K.N.), and Michigan Center for Integrative Research in Critical Care (S.S.S., M.W.S., H.C.P., T.J.I., C.R.C., B.K.N.), University of Michigan, Ann Arbor; and Center for Clinical Management Research, Ann Arbor Veterans Affairs Healthcare System, MI (H.C.P., T.J.I., H.S.G., B.K.N.)
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