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Sacco A, Montisci A, Tavecchia G, Frea S, Bernasconi D, Colombo CNJ, Bertolin S, Viola G, Villanova L, Briani M, Patrini L, Bocchino PP, Sorini Dini C, D'Ettore N, Bertaina M, Iannaccone M, Potena L, Bertoldi L, Valente S, Camporotondo R, Marini M, Pagnesi M, Metra M, De Ferrari G, Oliva F, Morici N, Pappalardo F, Tavazzi G. Ventilation strategies in cardiogenic shock: Insights from the AltShock-2 registry. Eur J Heart Fail 2024. [PMID: 39105476 DOI: 10.1002/ejhf.3409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/27/2024] [Accepted: 07/15/2024] [Indexed: 08/07/2024] Open
Abstract
AIMS To describe the use and the relation to outcome of different ventilation strategies in a contemporary, large, prospective registry of cardiogenic shock patients. METHODS AND RESULTS Among 657 patients enrolled from March 2020 to November 2023, 198 (30.1%) received oxygen therapy (OT), 96 (14.6%) underwent non-invasive ventilation (NIV), and 363 (55.3%) underwent invasive mechanical ventilation (iMV). Patients in the iMV group were significantly younger compared to those in the NIV and OT groups (63 vs. 69 years, p < 0.001). There were no significant differences between groups regarding cardiovascular risk factors. Patients with SCAI B and C were more frequently treated with OT and NIV compared to iMV (65.1% and 65.4% vs. 42.6%, respectively, p > 0.001), while the opposite trend was observed in SCAI D patients (12% and 12.2% vs. 30.9%, respectively, p < 0.001). All-cause mortality at 24 h did not differ amongst the three groups. The 60-day mortality rates were 40.2% for the iMV group, 26% for the OT group, and 29.3% for the NIV group (p = 0.005), even after excluding patients with cardiac arrest at presentation. In the multivariate analysis including SCAI stages, NIV was not associated with worse mortality compared to iMV (hazard ratio 1.97, 95% confidence interval 0.85-4.56), even in more severe SCAI stages such as D. CONCLUSIONS Compared to previous studies, we observed a rising trend in the utilization of NIV among cardiogenic shock patients, irrespective of aetiology and SCAI stages. In this clinical scenario, NIV emerges as a safe option for appropriately selected patients.
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Affiliation(s)
- Alice Sacco
- Cardiac Intensive Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Montisci
- Division of Cardiothoracic Intensive Care, ASST Spedali Civili, Brescia, Italy
| | - Giovanni Tavecchia
- Cardiac Intensive Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Simone Frea
- Intensive Cardiac Care Unit, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Davide Bernasconi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre - B4, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy and Functional Department for Higher Education, Research, and Development, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Costanza N J Colombo
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences University of Pavia, Pavia, Italy
- Anestesia e Rianimazione I, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Stephanie Bertolin
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Giovanna Viola
- Cardiac Intensive Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Luca Villanova
- Cardiac Intensive Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Lisa Patrini
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences University of Pavia, Pavia, Italy
| | - Pier Paolo Bocchino
- Intensive Cardiac Care Unit, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Carlotta Sorini Dini
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | | | - Maurizio Bertaina
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Mario Iannaccone
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Luciano Potena
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | | | - Serafina Valente
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Rita Camporotondo
- Cardiology Unit, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Marco Marini
- Department of Cardiovascular Sciences, Clinic of Cardiology, Ospedali Riuniti, Ancona, Italy
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gaetano De Ferrari
- Intensive Cardiac Care Unit, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Fabrizio Oliva
- Cardiac Intensive Care Unit, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nuccia Morici
- IRCCS S. Maria Nascente - Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | | | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences University of Pavia, Pavia, Italy
- Anestesia e Rianimazione I, Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
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Jentzer JC, van Diepen S, Alviar C, Miller PE, Metkus TS, Geller BJ, Kashani KB. Arterial hyperoxia and mortality in the cardiac intensive care unit. Curr Probl Cardiol 2024; 49:102738. [PMID: 39025170 DOI: 10.1016/j.cpcardiol.2024.102738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 07/04/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Arterial hyperoxia (hyperoxemia), defined as a high arterial partial pressure of oxygen (PaO2), has been associated with adverse outcomes in critically ill populations, but has not been examined in the cardiac intensive care unit (CICU). We evaluated the association between exposure to hyperoxia on admission with in-hospital mortality in a mixed CICU cohort. METHODS We included unique Mayo Clinic CICU patients admitted from 2007 to 2018 with admission PaO2 data (defined as the PaO2 value closest to CICU admission) and no hypoxia (PaO2 < 60mmHg). The admission PaO2 was evaluated as a continuous variable and categorized (60-100 mmHg, 101-150 mmHg, 151-200 mmHg, 201-300 mmHg, >300 mmHg). Logistic regression was used to evaluate predictors of in-hospital mortality before and after multivariable adjustment. RESULTS We included 3,368 patients with a median age of 70.3 years; 70.3% received positive-pressure ventilation. The median PaO2 was 99 mmHg, with a distribution as follows: 60-100 mmHg, 51.9%; 101-150 mmHg, 28.6%; 151-200 mmHg, 10.6%; 201-300 mmHg, 6.4%; >300 mmHg, 2.5%. A J-shaped association between admission PaO2 and in-hospital mortality was observed, with a nadir around 100 mmHg. A higher PaO2 was associated with increased in-hospital mortality (adjusted OR 1.17 per 100 mmHg higher, 95% CI 1.01-1.34, p = 0.03). Patients with PaO2 >300 mmHg had higher in-hospital mortality versus PaO2 60-100 mmHg (adjusted OR 2.37, 95% CI 1.41-3.94, p < 0.001). CONCLUSIONS Hyperoxia at the time of CICU admission is associated with higher in-hospital mortality, primarily in those with severely elevated PaO2 >300 mmHg.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States.
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Carlos Alviar
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York, United States
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Thomas S Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Bram J Geller
- Division of Cardiovascular Medicine and Division of Cardiovascular Critical Care, Maine Medical Center, Portland, ME, United States
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States
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3
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Randhawa VK, Lee R, Alviar CL, Rali AS, Arias A, Vaidya A, Zern EK, Fagan A, Proudfoot AG, Katz JN. Extra-cardiac management of cardiogenic shock in the intensive care unit. J Heart Lung Transplant 2024; 43:1051-1058. [PMID: 38823968 DOI: 10.1016/j.healun.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 06/03/2024] Open
Abstract
Cardiogenic shock (CS) is a heterogeneous clinical syndrome characterized by low cardiac output leading to end-organ hypoperfusion. Organ dysoxia ranging from transient organ injury to irreversible organ failure and death occurs across all CS etiologies but differing by incidence and type. Herein, we review the recognition and management of respiratory, renal and hepatic failure complicating CS. We also discuss unmet needs in the CS care pathway and future research priorities for generating evidence-based best practices for the management of extra-cardiac sequelae. The complexity of CS admitted to the contemporary cardiac intensive care unit demands a workforce skilled to care for these extra-cardiac critical illness complications with an appreciation for how cardio-systemic interactions influence critical illness outcomes in afflicted patients.
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Affiliation(s)
- Varinder K Randhawa
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Division of Cardiology, St Michael's Hospital, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ran Lee
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Sections of Critical Care Cardiology and Advanced Heart Failure and Transplant Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carlos L Alviar
- The Leon H Charney Division of Cardiovascular Medicine, NYU Langone Medical Center, New York, New York
| | - Aniket S Rali
- Department of Internal Medicine, Division of Cardiovascular Diseases, and Department of Anesthesiology, Division of Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexandra Arias
- Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program, Division of Cardiology, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Emily K Zern
- Department of Cardiology, Keck School of Medicine of University of Southern California, Los Angeles General Medicine Center, Los Angeles General Medical Center, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Andrew Fagan
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Jason N Katz
- Division of Cardiology, NYU Grossman School of Medicine and Bellevue Hospital Center, New York, New York.
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Rali AS, Tran L, Balakrishna A, Senussi M, Kapur NK, Metkus T, Tedford RJ, Lindenfeld J. Guide to Lung-Protective Ventilation in Cardiac Patients. J Card Fail 2024; 30:829-837. [PMID: 38513887 DOI: 10.1016/j.cardfail.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 03/23/2024]
Abstract
The incidence of acute respiratory insufficiency has continued to increase among patients admitted to modern-day cardiovascular intensive care units. Positive pressure ventilation (PPV) remains the mainstay of treatment for these patients. Alterations in intrathoracic pressure during PPV has distinct effects on both the right and left ventricles, affecting cardiovascular performance. Lung-protective ventilation (LPV) minimizes the risk of further lung injury through ventilator-induced lung injury and, hence, an understanding of LPV and its cardiopulmonary interactions is beneficial for cardiologists.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN.
| | - Lena Tran
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN
| | - Aditi Balakrishna
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Mourad Senussi
- Department of Medicine, Baylor St. Luke's Medical Center, Houston, TX
| | - Navin K Kapur
- Division of Cardiovascular Diseases, Tufts Medical Center, Boston, MA
| | - Thomas Metkus
- Departments of Medicine and Surgery, Divisions of Cardiology and Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ryan J Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Joann Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, TN
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5
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Schenck CS, Chouairi F, Dudzinski DM, Miller PE. Noninvasive Ventilation in the Cardiac Intensive Care Unit. J Intensive Care Med 2024:8850666241243261. [PMID: 38571399 DOI: 10.1177/08850666241243261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Over the last several decades, the cardiac intensive care unit (CICU) has seen an increase in the complexity of the patient population and etiologies requiring CICU admission. Currently, respiratory failure is the most common reason for admission to the contemporary CICU. As a result, noninvasive ventilation (NIV), including noninvasive positive-pressure ventilation and high-flow nasal cannula, has been increasingly utilized in the management of patients admitted to the CICU. In this review, we detail the different NIV modalities and summarize the evidence supporting their use in conditions frequently encountered in the CICU. We describe the unique pathophysiologic interactions between positive pressure ventilation and left and/or right ventricular dysfunction. Additionally, we discuss the evidence and strategies for utilization of NIV as a method to reduce extubation failure in patients who required invasive mechanical ventilation. Lastly, we examine unique considerations for managing respiratory failure in certain, high-risk patient populations such as those with right ventricular failure, severe valvular disease, and adult congenital heart disease. Overall, it is critical for clinicians who practice in the CICU to be experts with the application, risks, benefits, and modalities of NIV in cardiac patients with respiratory failure.
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Affiliation(s)
| | - Fouad Chouairi
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - David M Dudzinski
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
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6
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Shahu A, Banna S, Applefeld W, Rampersad P, Alviar CL, Ali T, Luk A, Fajardo E, van Diepen S, Miller PE. Liberation From Mechanical Ventilation in the Cardiac Intensive Care Unit. JACC. ADVANCES 2023; 2:100173. [PMID: 38939038 PMCID: PMC11198553 DOI: 10.1016/j.jacadv.2022.100173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/18/2022] [Accepted: 11/16/2022] [Indexed: 06/29/2024]
Abstract
The prevalence of respiratory failure is increasing in the contemporary cardiac intensive care unit (CICU) and is associated with a significant increase in morbidity and mortality. For patients that survive their initial respiratory decompensation, liberation from invasive mechanical ventilation (IMV) and the decision to extubate requires careful clinical assessment and planning. Therefore, it is essential for the CICU clinician to know how to assess and manage the various stages of IMV liberation, including ventilator weaning, evaluation of extubation readiness, and provide post-extubation care. In this review, we provide a comprehensive approach to liberation from IMV in the CICU, including cardiopulmonary interactions relative to withdrawal from positive pressure ventilation, evaluation of readiness for and assessment of spontaneous breathing trials, sedation management to optimize extubation, strategies for patients at a high risk for extubation failure, and tracheostomy in the cardiovascular patient.
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Affiliation(s)
- Andi Shahu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Soumya Banna
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Willard Applefeld
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Penelope Rampersad
- The Tomsich Family Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Connecticut, USA
| | - Carlos L. Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Langone Medicine Center, New York, New York, USA
| | - Tariq Ali
- Division of Pulmonary and Critical Care, Mayo, Rochester, Minnesota, USA
| | - Adriana Luk
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Elaine Fajardo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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7
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Amado-Rodríguez L, Rodríguez-Garcia R, Bellani G, Pham T, Fan E, Madotto F, Laffey JG, Albaiceta GM. Mechanical ventilation in patients with cardiogenic pulmonary edema: a sub-analysis of the LUNG SAFE study. J Intensive Care 2022; 10:55. [PMID: 36567347 PMCID: PMC9791731 DOI: 10.1186/s40560-022-00648-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/18/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Patients with acute respiratory failure caused by cardiogenic pulmonary edema (CPE) may require mechanical ventilation that can cause further lung damage. Our aim was to determine the impact of ventilatory settings on CPE mortality. METHODS Patients from the LUNG SAFE cohort, a multicenter prospective cohort study of patients undergoing mechanical ventilation, were studied. Relationships between ventilatory parameters and outcomes (ICU discharge/hospital mortality) were assessed using latent mixture analysis and a marginal structural model. RESULTS From 4499 patients, 391 meeting CPE criteria (median age 70 [interquartile range 59-78], 40% female) were included. ICU and hospital mortality were 34% and 40%, respectively. ICU survivors were younger (67 [57-77] vs 74 [64-80] years, p < 0.001) and had lower driving (12 [8-16] vs 15 [11-17] cmH2O, p < 0.001), plateau (20 [15-23] vs 22 [19-26] cmH2O, p < 0.001) and peak (21 [17-27] vs 26 [20-32] cmH2O, p < 0.001) pressures. Latent mixture analysis of patients receiving invasive mechanical ventilation on ICU day 1 revealed a subgroup ventilated with high pressures with lower probability of being discharged alive from the ICU (hazard ratio [HR] 0.79 [95% confidence interval 0.60-1.05], p = 0.103) and increased hospital mortality (HR 1.65 [1.16-2.36], p = 0.005). In a marginal structural model, driving pressures in the first week (HR 1.12 [1.06-1.18], p < 0.001) and tidal volume after day 7 (HR 0.69 [0.52-0.93], p = 0.015) were related to survival. CONCLUSIONS Higher airway pressures in invasively ventilated patients with CPE are related to mortality. These patients may be exposed to an increased risk of ventilator-induced lung injury. Trial registration Clinicaltrials.gov NCT02010073.
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Affiliation(s)
- Laura Amado-Rodríguez
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain
- Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain
| | - Raquel Rodríguez-Garcia
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Tài Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU 4 CORREVE Maladies du Cœur et des Vaisseaux, FHU Sepsis, Groupe de Recherche Clinique CARMAS, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, UVSQ, Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, 94807, Villejuif, France
| | - Eddy Fan
- Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Fabiana Madotto
- Department of Anesthesia, Critical Care and Emergency' Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland
- School of Medicine, Regenerative Medicine Institute at CÚRAM Centre for Research in Medical Devices, University of Galway, Galway, Ireland
| | - Guillermo M Albaiceta
- Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain.
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Avenida del Hospital Universitario s/n, 33011, Oviedo, Spain.
- Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain.
- Centro de Investigación Biomédica en Red (CIBER)-Enfermedades Respiratorias, Madrid, Spain.
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8
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Cardiovascular Critical Care Training: A Collaboration between Intensivists and Cardiologists. ATS Sch 2022; 3:522-534. [PMID: 36726709 PMCID: PMC9885994 DOI: 10.34197/ats-scholar.2022-0087ps] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/21/2022] [Indexed: 11/13/2022] Open
Abstract
With growing patient complexity, the cardiovascular intensive care unit (CICU) of today has evolved substantially from the coronary care unit (CCU) of decades ago. The growing burden of noncardiac critical illness and highly specialized acute cardiovascular disease requires a degree of expertise beyond that afforded through a general cardiology training program. Therefore, the American Heart Association (AHA) has proposed a CICU staffing model to include dedicated cardiac intensivists; in the present day, "dual-trained" physicians are extremely sparse. Guidance on designing critical care fellowships for cardiologists is limited but will require collaboration between cardiologists and medical intensivists. Here, we review the evolution of the CICU, describe training pathways, and offer guidance on creating a cardiology critical care training program.
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9
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Relation of Ischemic Heart Disease to Outcomes in Patients With Acute Respiratory Distress Syndrome. Am J Cardiol 2022; 176:24-29. [PMID: 35606175 DOI: 10.1016/j.amjcard.2022.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/21/2022]
Abstract
Patients with ischemic heart disease (IHD) are often excluded from acute respiratory distress syndrome (ARDS) clinical trials. As a result, little is known about the impact of IHD in this population. We sought to assess the association between IHD and clinical outcomes in patients with ARDS. Participants from 4 ARDS randomized controlled trials with shared study criteria, definitions, and end points were included. Using multivariable logistic regression, we assessed for the association between IHD and a primary outcome of 60-day mortality. Secondary outcomes included 90-day mortality, 28-day ventilator-free days, and 28-day organ failure. Among 1,909 patients, 102 had a history of IHD (5.4%). Patients with IHD were more likely to be older and male (p <0.05). Noncardiac co-morbidities, severity of illness, and other markers of ARDS severity were not statistically different (all, p >0.05). Patients with IHD had a higher 60-day (39.2% vs 23.3%, p <0.001) and 90-day (40.2% vs 24.0%, p <0.001) mortality, and experienced more frequent renal (45.1% vs 32.0%, p = 0.006) and hepatic (35.3% vs 25.2%, p = 0.023) failure. After multivariable adjustment, 60-day (odds ratio [OR] 1.76; 95% confidence interval [CI]: 1.07 to 2.89, p = 0.025) and 90-day (OR 1.74; 95% CI: 1.06 to 2.85, p = 0.028) mortality remained higher. IHD was associated with 10% fewer ventilator-free days (incidence rate ratio 0.90; 95% CI: 0.85 to 0.96, p = 0.001). In conclusion, co-morbid IHD was associated with higher mortality and fewer ventilator-free days in patients with ARDS. Future studies are needed to identify predictors of mortality and improve treatment paradigms in this critically ill subgroup of patients.
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10
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Thomas A, van Diepen S, Beekman R, Sinha SS, Brusca SB, Alviar CL, Jentzer J, Bohula EA, Katz JN, Shahu A, Barnett C, Morrow DA, Gilmore EJ, Solomon MA, Miller PE. Oxygen Supplementation and Hyperoxia in Critically Ill Cardiac Patients: From Pathophysiology to Clinical Practice. JACC. ADVANCES 2022; 1:100065. [PMID: 36238193 PMCID: PMC9555075 DOI: 10.1016/j.jacadv.2022.100065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Oxygen supplementation has been a mainstay in the management of patients with acute cardiac disease. While hypoxia is known to be detrimental, the adverse effects of artificially high oxygen levels (hyperoxia) have only recently been recognized. Hyperoxia may induce harmful hemodynamic effects, including peripheral and coronary vasoconstriction, and direct cellular toxicity through the production of reactive oxygen species. In addition, emerging evidence has shown that hyperoxia is associated with adverse clinical outcomes. Thus, it is essential for the cardiac intensive care unit (CICU) clinician to understand the available evidence and titrate oxygen therapies to specific goals. This review summarizes the pathophysiology of oxygen within the cardiovascular system and the association between supplemental oxygen and hyperoxia in patients with common CICU diagnoses, including acute myocardial infarction, heart failure, shock, cardiac arrest, pulmonary hypertension, and respiratory failure. Finally, we highlight lessons learned from available trials, gaps in knowledge, and future directions.
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Affiliation(s)
- Alexander Thomas
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Rachel Beekman
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA
| | - Samuel B. Brusca
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - Carlos L. Alviar
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
| | - Jacob Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Erin A. Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jason N. Katz
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Andi Shahu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Christopher Barnett
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Emily J. Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - 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
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
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11
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Abraham J, Blumer V, Burkhoff D, Pahuja M, Sinha SS, Rosner C, Vorovich E, Grafton G, Bagnola A, Hernandez-Montfort JA, Kapur NK. Heart Failure-Related Cardiogenic Shock: Pathophysiology, Evaluation and Management Considerations: Review of Heart Failure-Related Cardiogenic Shock. J Card Fail 2021; 27:1126-1140. [PMID: 34625131 DOI: 10.1016/j.cardfail.2021.08.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/27/2021] [Accepted: 08/09/2021] [Indexed: 12/23/2022]
Abstract
Despite increasing prevalence in critical care units, cardiogenic shock related to HF (HF-CS) is incompletely understood and distinct from acute myocardial infarction related CS. This review highlights the pathophysiology, evaluation, and contemporary management of HF-CS.
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Affiliation(s)
- Jacob Abraham
- Providence Heart Institute, Center for Cardiovascular Analytics, Research, and Data Science (CARDS), Providence St. Joseph Health, Portland, Oregon
| | - Vanessa Blumer
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Dan Burkhoff
- Cardiovascular Research Foundation, New York, New York
| | - Mohit Pahuja
- Medstar Georgetown University Hospital, Washington, D.C
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia
| | | | | | - Gillian Grafton
- The Ohio State University Wexner Medical Center, Department of Pharmacy, Columbus, Ohio
| | - Aaron Bagnola
- Heart and Vascular Institute, Cleveland Clinic Florida, Weston, Florida
| | | | - Navin K Kapur
- The Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts.
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12
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Metkus TS, Lindsley J, Fair L, Riley S, Berry S, Sahetya S, Hsu S, Gilotra NA. Quality of Heart Failure Care in the Intensive Care Unit. J Card Fail 2021; 27:1111-1125. [PMID: 34625130 DOI: 10.1016/j.cardfail.2021.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 01/02/2023]
Abstract
Patients with heart failure (HF) who are seen in an intensive care unit (ICU) manifest the highest-risk, most complex and most resource-intensive disease states. These patients account for a large relative proportion of days spent in an ICU. The paradigms by which critical care is provided to patients with HF are being reconsidered, including consideration of various multidisciplinary ICU staffing models and the development of acute-response teams. Traditional HF quality initiatives have centered on the peri- and postdischarge period in attempts to improve adherence to guideline-directed therapies and reduce readmissions. There is a compelling rationale for expanding high-quality efforts in treating patients with HF who are receiving critical care so we can improve outcomes, reduce preventable harm, improve teamwork and resource use, and achieve high health-system performance. Our goal is to answer the following question: For a patient with HF in the ICU, what is required for the provision of high-quality care? Herein, we first review the epidemiology of HF syndromes in the ICU and identify relevant critical care and quality stakeholders in HF. We next discuss the tenets of high-quality care for patients with HF in the ICU that will optimize critical care outcomes, such as ICU staffing models and evidence-based management of cardiac and noncardiac disease. We discuss strategies to mitigate preventable harm, improve ICU culture and conduct outcomes review, and we conclude with our summative vision of high-quality of ICU care for patients with HF; our vision includes clinical excellence, teamwork and ICU culture.
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Affiliation(s)
- Thomas S Metkus
- The Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | - Linda Fair
- Johns Hopkins Hospital, Baltimore, Maryland
| | - Sarah Riley
- The Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen Berry
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sarina Sahetya
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven Hsu
- The Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nisha A Gilotra
- The Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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