Pulmonary Hypertension an Independent Risk Factor for Death in Intensive Care Unit: Correlation of Hemodynamic Factors with Mortality

Pulmonary hypertension: An unexplored risk factor for stroke in patients with atrial fibrillation

BACKGROUND

Atrial fibrillation (Afib) is one of the most common and significant risk factors for stroke, with the CHADsVAsc score used as the tool for stroke risk assessment. Pulmonary hypertension (PH) has not been studied as an independent risk factor for stroke in individuals with Afib.

METHODS

In this retrospective case-control study, National Inpatient Sample Database was used to sample individuals with atrial fibrillation, and baseline demographics and comorbidities were collected using ICD-10 codes. Patients with missing data, age under 18, history of thromboembolic diseases, or stroke were excluded. Greedy propensity matching using R was performed to match patients with and without PH on age, race, gender, and 19 other comorbidities, including anticoagulation use. Binary logistic regression was performed after matching to assess whether PH was an independent risk factor for stroke. A p-value of <0.05 was considered statistically significant.

RESULTS

Of the 2,421,545 patients included in the study, 158,545 (6.5%) had PH. PH patients were more likely to be elderly, females, and smokers. Comorbidities were more common in the PH group. Patients with PH were more likely to have an ischemic stroke (3.6% vs. 2.9%, p<0.001), hemorrhagic stroke (2.2% vs. 0.7%, p<0.001), and transient ischemic attack (TIA) (2.3% vs. 0.7%, p<0.001). After matching, the presence of PH was associated with increased ischemic stroke (OR: 1.2 [1.1-1.2]; p<0.001), hemorrhagic stroke (OR: 2.4 [2.1-2.6]; p<0.001) and TIA (OR: 2.2 [2.0-2.4]; p<0.001). PH patients also had increased length of stay (β = 0.8; p<0.001) mortality (OR: 1.1 [1.0-1.2]; p<0.001).

CONCLUSION

Apart from demonstrating the deleterious effect of PH on mortality and length of hospital stay, this study is the first to report on such a large scale that PH independently increases the incidence of all types of strokes in patients with Afib.

Association of Glasgow coma scale and endotracheal intubation in predicting mortality among patients admitted to the intensive care unit

BACKGROUND

We assessed predictors of mortality in the intensive care unit (ICU) and investigated if Glasgow coma scale (GCS) is associated with mortality in patients undergoing endotracheal intubation (EI).

METHODS

From February 2020, we performed a 1-year study on 2,055 adult patients admitted to the ICU of two teaching hospitals. The outcome was mortality during ICU stay and the predictors were patients' demographic, clinical, and laboratory features.

RESULTS

EI was associated with a decreased risk for mortality compared with similar patients (adjusted odds ratio [AOR], 0.32; P=0.030). This shows that EI had been performed correctly with proper indications. Increasing age (AOR, 1.04; P<0.001) or blood pressure (AOR, 1.01; P<0.001), respiratory problems (AOR, 3.24; P<0.001), nosocomial infection (AOR, 1.64; P=0.014), diabetes (AOR, 5.69; P<0.001), history of myocardial infarction (AOR, 2.52; P<0.001), chronic obstructive pulmonary disease (AOR, 3.93; P<0.001), immunosuppression (AOR, 3.15; P<0.001), and the use of anesthetics/sedatives/hypnotics for reasons other than EI (AOR, 4.60; P<0.001) were directly; and GCS (AOR, 0.84; P<0.001) was inversely related to mortality. In patients with trauma surgeries (AOR, 0.62; P=0.014) or other surgical categories (AOR, 0.61; P=0.024) undergoing EI, GCS had an inverse relation with mortality (accuracy=82.6%, area under the receiver operator characteristic curve=0.81).

CONCLUSIONS

A variety of features affected the risk for mortality in patients admitted to the ICU. Considering GCS score for EI had the potential of affecting prognosis in subgroups of patients such as those with trauma surgeries or other surgical categories.

Longitudinal Validation of Right Ventricular Pressure Monitoring for the Assessment of Right Ventricular Systolic Dysfunction in a Large Animal Ischemic Model

Right ventricular (RV) dysfunction is a major cause of morbidity and mortality in intensive care and cardiac surgery. Early detection of RV dysfunction may be facilitated by continuous monitoring of RV waveform obtained from a pulmonary artery catheter. The objective is to evaluate the extent to which RV pressure monitoring can detect changes in RV systolic performance assess by RV end-systolic elastance (E_es) following the development of an acute RV ischemic in a porcine model.

HYPOTHESIS

RV pressure monitoring can detect changes in RV systolic performance assess by RV E_es following the development of an acute RV ischemic model.

METHODS AND MODELS

Acute ischemic RV dysfunction was induced by progressive embolization of microsphere in the right coronary artery to mimic RV dysfunction clinically experienced during cardiopulmonary bypass separation caused by air microemboli. RV hemodynamic performance was assessed using RV pressure waveform-derived parameters and RV E_es obtained using a conductance catheter during inferior vena cava occlusions.

RESULTS

Acute ischemia resulted in a significant reduction in RV E_es from 0.26 mm Hg/mL (interquartile range, 0.16-0.32 mm Hg/mL) to 0.14 mm Hg/mL (0.11-0.19 mm Hg/mL; p < 0.010), cardiac output from 6.3 L/min (5.7-7 L/min) to 4.5 (3.9-5.2 L/min; p = 0.007), mean systemic arterial pressure from 72 mm Hg (66-74 mm Hg) to 51 mm Hg (46-56 mm Hg; p < 0.001), and mixed venous oxygen saturation from 65% (57-72%) to 41% (35-45%; p < 0.001). Linear mixed-effect model analysis was used to assess the relationship between E_es and RV pressure-derived parameters. The reduction in RV E_es best correlated with a reduction in RV maximum first derivative of pressure during isovolumetric contraction (dP/dt_max) and single-beat RV E_es. Adjusting RV dP/dt_max for heart rate resulted in an improved surrogate of RV E_es.

INTERPRETATION AND CONCLUSIONS

Stepwise decreases in RV E_es during acute ischemic RV dysfunction were accurately tracked by RV dP/dt_max derived from the RV pressure waveform.

Risk factors for mortality in ICU patients in 10 middle eastern countries: The role of healthcare-associated infections

PURPOSE

The International Nosocomial Infection Control Consortium (INICC) found a high mortality rate in ICUs of the Middle East (ME). Our goal was to identify mortality risk factor (RF) in ICUs of the ME.

MATERIALS

From 08/01/2003 to 02/12/2022, we conducted a prospective cohort study in 236 ICUs of 77 hospitals in 44 cities in 10 countries of ME. We analyzed 16 independent variables using multiple logistic regression.

RESULTS

66,440 patients, hospitalized during 652,167 patient-days, and 13,974 died. We identified following mortality RF: Age (adjusted odds ratio (aOR):1.02;p < 0.0001) rising risk 2% yearly; length of stay (LOS) (aOR:1.02;p < 0.0001) rising the risk 2% per day; central line (CL)-days (aOR:1.01;p < 0.0001) rising risk 1% per day; mechanicalventilator (MV) utilization-ratio (aOR:14.51;p < 0.0001); CL-associated bloodstream infection (CLABSI) acquisition (aOR):1.49;p < 0.0001); ventilator-associated pneumonia (VAP) acquisition (aOR:1.50;p < 0.0001); female gender (OR:1.14;p < 0.0001); hospitalization at a public-hospital (OR:1.31;p < 0.0001); and medical-hospitalization (aOR:1.64;p < 0.0001). High-income countries showed lowest risk (aOR:0.59;p < 0.0001).

CONCLUSION

Some identified RF are unlikely to change, such as country income-level, facility ownership, hospitalization type, gender, and age. Some can be modified; LOS, CL-use, MV-use, CLABSI, VAP. So, to lower the mortality risk in ICUs, we recommend focusing on strategies to shorten the LOS, reduce CL and MV-utilization, and use evidence-based recommendations to prevent CLABSI and VAP.

Therapeutic Effects of Inhaled Nitric Oxide Therapy in COVID-19 Patients

The global COVID-19 pandemic has become the largest public health challenge of recent years. The incidence of COVID-19-related acute hypoxemic respiratory failure (AHRF) occurs in up to 15% of hospitalized patients. Antiviral drugs currently available to clinicians have little to no effect on mortality, length of in-hospital stay, the need for mechanical ventilation, or long-term effects. Inhaled nitric oxide (iNO) administration is a promising new non-standard approach to directly treat viral burden while enhancing oxygenation. Along with its putative antiviral affect in COVID-19 patients, iNO can reduce inflammatory cell-mediated lung injury by inhibiting neutrophil activation, lowering pulmonary vascular resistance and decreasing edema in the alveolar spaces, collectively enhancing ventilation/perfusion matching. This narrative review article presents recent literature on the iNO therapy use for COVID-19 patients. The authors suggest that early administration of the iNO therapy may be a safe and promising approach for the treatment of COVID-19 patients. The authors also discuss unconventional approaches to treatment, continuous versus intermittent high-dose iNO therapy, timing of initiation of therapy (early versus late), and novel delivery systems. Future laboratory and clinical research is required to define the role of iNO as an adjunct therapy against bacterial, viral, and fungal infections.

Critical Care Management of Decompensated Right Heart Failure in Pulmonary Arterial Hypertension Patients - An Ongoing Approach

Despite substantial advancements in diagnosis and specific medical therapy in pulmonary arterial hypertension patients’ management, this condition continues to represent a major cause of mortality worldwide. In pulmonary arterial hypertension, the continuous increase of pulmonary vascular resistance and rapid development of right heart failure determine a poor prognosis. Against targeted therapy, patients inexorable deteriorate over time. Pulmonary arterial hypertension patients with acute right heart failure who need intensive care unit admission present a complexity of the disease pathophysiology. Intensive care management challenges are multifaceted. Awareness of algorithms of right-sided heart failure monitoring in intensive care units, targeted pulmonary hypertension therapies, and recognition of precipitating factors, hemodynamic instability and progressive multisystem organ failure requires a multidisciplinary pulmonary hypertension team. This paper summarizes the management strategies of acute right-sided heart failure in pulmonary arterial hypertension adult cases based on recently available data.

Critical care outcomes in patients with pre-existing pulmonary hypertension: insights from the ASPIRE registry

Pulmonary hypertension (PH) is a life-shortening condition characterised by episodes of decompensation precipitated by factors such as disease progression, arrhythmias and sepsis. Surgery and pregnancy also place additional strain on the right ventricle. Data on critical care management in patients with pre-existing PH are scarce.

We conducted a retrospective observational study of a large cohort of patients admitted to the critical care unit of a national referral centre between 2000–2017 to establish acute mortality, evaluate predictors of in-hospital mortality and establish longer term outcomes in survivors to hospital discharge.

242 critical care admissions involving 206 patients were identified. Hospital survival was 59.3%, 94% and 92% for patients admitted for medical, surgical or obstetric reasons, respectively. Medical patients had more severe physiological and laboratory perturbations than patients admitted following surgical or obstetric interventions. Higher APACHE II (Acute Physiology and Chronic Health Evaluation) score, age and lactate, and lower oxygen saturation measure by pulse oximetry/inspiratory oxygen fraction (S_pO2/F_iO2) ratio, platelet count and sodium level were identified as independent predictors of hospital mortality. An exploratory risk score, OPALS (oxygen (S_pO2/F_iO2) ≤185; platelets ≤196×10⁹·L⁻¹; age ≥37.5 years; lactate ≥2.45 mmol·L⁻¹; sodium ≤130.5 mmol·L⁻¹), identified medical patients at increasing risk of hospital mortality. One (11%) out of nine patients who were invasively ventilated for medical decompensation and 50% of patients receiving renal replacement therapy left hospital alive. There was no significant difference in exercise capacity or functional class between follow-up and pre-admission in patients who survived to discharge.

These data have clinical utility in guiding critical care management of patients with known PH. The exploratory OPALS score requires validation.

Critical care survival is worse in PH patients admitted for medical rather than surgical/obstetric indications. Nevertheless, many show longer term survival and functional recovery. Markers of severity of acute illness at admission are prognostic.https://bit.ly/2YX9Fw9

The contemporary pulmonary artery catheter. Part 2: measurements, limitations, and clinical applications

Nowadays, the classical pulmonary artery catheter (PAC) has an almost 50-year-old history of its clinical use for hemodynamic monitoring. In recent years, the PAC evolved from a device that enabled intermittent cardiac output measurements in combination with static pressures to a monitoring tool that provides continuous data on cardiac output, oxygen supply and-demand balance, as well as right ventricular performance. In this review, which consists of two parts, we will introduce the difference between intermittent pulmonary artery thermodilution using bolus injections, and the contemporary PAC enabling continuous measurements by using a thermal filament which heats up the blood. In this second part, we will discuss in detail the measurements of the contemporary PAC, including continuous cardiac output measurement, right ventricular ejection fraction, end-diastolic volume index, and mixed venous oxygen saturation. Limitations of all of these measurements are highlighted as well. We conclude that thorough understanding of measurements obtained from the PAC is the first step in successful application of the PAC in daily clinical practice.

Pulmonary Hypertension in Intensive Care Units: An Updated Review

Pulmonary hypertension (PH) is a condition associated with high morbidity and mortality. Patients with PH who require critical care usually have severe right ventricular (RV) dysfunction. Although different groups of PH have different etiologies, pulmonary vascular dysfunction is common in these groups. PH can lead to increased pulmonary artery pressure, which can ultimately cause RV failure. Clinicians should be familiar with the presentations of this disease and diagnostic tools. The contributing factors, if present (e.g., sepsis), and coexisting conditions (e.g., arrhythmias) should be identified and addressed accordingly. The preload should be optimized by fluid administration, diuretics, and dialysis, if necessary. On the other hand, the RV afterload should be reduced to improve the RV function with pulmonary vasodilators, such as prostacyclins, inhaled nitric oxide, and phosphodiesterase type 5 inhibitors, especially in group 1 PH. Inotropes are also used to improve RV contractility, and if inadequate, use of ventricular assist devices and extracorporeal life support should be considered in suitable candidates. Moreover, vasopressors should be used to maintain systemic blood pressure, albeit cautiously, as they increase the RV afterload. Measures should be also taken to ensure adequate oxygenation. However, mechanical ventilation is avoided in RV failure. In this study, we reviewed the pathophysiology, manifestations, diagnosis, monitoring, and management strategies of PH, especially in intensive care units.

Noninvasive Administration of Inhaled Nitric Oxide and its Hemodynamic Effects in Patients With Acute Right Ventricular Dysfunction

OBJECTIVE

The authors aimed to assess the hemodynamic effects and demonstrate the feasibility of inhaled nitric oxide (iNO) in hemodynamically unstable patients with acute right ventricular (RV) dysfunction and to explore the safety profile of this approach.

DESIGN

Retrospective cohort study.

SETTING

Intensive care unit (ICU) of 2 tertiary care centers between January 2013 and 2017.

PARTICIPANTS

All patients with RV dysfunction in whom iNO was initiated without invasive mechanical ventilation.

INTERVENTION

Noninvasive administration of iNO.

MEASUREMENTS AND MAIN RESULTS

Eighteen patients received the intervention during the study period; 8 of these patients had a pulmonary artery catheter and 2 had a pulse contour analysis device. Median (interquartile range) iNO concentration was 20 (20-20) ppm, and therapy duration was 24 (12-46) hours. Most patients received iNO through nasal prongs (66.7%) or a high-flow nasal cannula (27.8%). Within 1 hour, iNO reduced pulmonary vascular resistance from 219.1 to 165.4 dyn•s/cm⁵ (n = 7; p < 0.001), mean pulmonary artery pressure from 28.4 to 25.3 mmHg (n = 8; p = 0.01), and central venous pressure from 17.5 to 13.1 mmHg (n = 16; p = 0.001). Indexed cardiac output increased from 2.0 to 2.6 L/min/m² (n = 9; p = 0.004). ICU mortality was 27.78%, and median ICU length of stay was 7 (5-9) days. Two significant bleeding episodes requiring intervention and 1 acute kidney injury occurred during iNO therapy. No headache was reported.

CONCLUSION

Noninvasively administered iNO was associated with favorable hemodynamic effects in ICU patients with acute RV dysfunction. These results suggest the safety and feasibility of this therapy for which further prospective study is warranted.

Non-invasive right ventricular load adaptability indices in patients with scleroderma-associated pulmonary arterial hypertension

Scleroderma-associated pulmonary arterial hypertension (SSc-PAH) is associated with worse outcome than idiopathic pulmonary arterial hypertension (IPAH), potentially due to worse right ventricular adaptation to load as suggested by pressure–volume loop analysis. The value of non-invasive load-adaptability metrics has not been fully explored in SSc-PAH. This study sought to assess whether patients with incident SSc-PAH have worse echocardiographic load-adaptability metrics than patients with IPAH. Twenty-two patients with incident SSc-PAH were matched 1:1 with IPAH based on pulmonary vascular resistance. Echocardiographic load-adaptability indices were divided into: surrogates of ventriculo-arterial coupling (e.g. right ventricular area change/end-systolic area), indices reflecting the proportionality of load adaptation (e.g. tricuspid regurgitation velocity-time integral normalized for average right ventricular radius), and simple ratios (e.g. tricuspid annular plane systolic excursion/right ventricular systolic pressure). The prognostic value of these indices for clinical worsening (i.e. death, transplant, or hospitalization for heart failure) at one year was explored. The two groups were comprised of patients of similar age, with similar cardiac index, pulmonary resistance, capacitance and NT-proBNP levels (p > 0.10). There was no difference in baseline right ventricular dimension, function or load-adaptability indices. At one year, eight (36.4%) SSc-PAH patients had experienced clinical worsening (eight hospitalizations and two deaths) versus one hospitalization in the IPAH group. Load adaptation at one year in survivors was not worse in SSc-PAH (p > 0.33). Patients with IPAH responded better to therapy than SSc-PAH in terms of reduction of right ventricular areas at one year (p < 0.05). Right ventricular load-adaptability echocardiographic indices do not appear to capture the increased risk of negative outcomes at one year associated with SSc-PAH.

Load Adaptability in Patients With Pulmonary Arterial Hypertension

Right ventricular (RV) adaptation to pressure overload is a major prognostic factor in patients with pulmonary arterial hypertension (PAH). The objectives were first to define the relation between RV adaptation and load using allometric modeling, then to compare the prognostic value of different indices of load adaptability in PAH. Both a derivation (n = 85) and a validation cohort (n = 200) were included. Load adaptability was assessed using 3 approaches: (1) surrogates of ventriculo-arterial coupling (e.g., RV area change/end-systolic area), (2) simple ratio of function and load (e.g., tricuspid annular plane systolic excursion/right ventricular systolic pressure), and (3) indices assessing the proportionality of adaptation using allometric pressure-function or size modeling. Proportional hazard modeling was used to compare the hazard ratio for the outcome of death or lung transplantation. The mean age of the derivation cohort was 44 ± 11 years, with 80% female and 74% in New York Heart Association class III or IV. Mean pulmonary vascular resistance index (PVRI) was 24 ± 11 with a wide distribution (1.6 to 57.5 WU/m²). Allometric relations were observed between PVRI and RV fractional area change (R² = 0.53, p < 0.001) and RV end-systolic area indexed to body surface area right ventricular end-systolic area index (RVESAI) (R² = 0.29, p < 0.001), allowing the derivation of simple ratiometric load-specific indices of RV adaptation. In right heart parameters, RVESAI was the strongest predictor of outcomes (hazard ratio per SD = 1.93, 95% confidence interval 1.37 to 2.75, p < 0.001). Although RVESAI/PVRI^0.35 provided small incremental discrimination on multivariate modeling, none of the load-adaptability indices provided stronger discrimination of outcome than simple RV adaptation metrics in either the derivation or the validation cohort. In conclusion, allometric modeling enables quantification of the proportionality of RV load adaptation but offers small incremental prognostic value to RV end-systolic dimension in PAH.

Right heart imaging in patients with heart failure: a tale of two ventricles

PURPOSE OF REVIEW

The purpose is to describe the recent advances made in imaging of the right heart, including deformation imaging, tissue, and flow characterization by MRI, and molecular imaging.

RECENT FINDINGS

Recent developments have been made in the field of deformation imaging of the right heart, which may improve risk stratification of patients with heart failure and pulmonary hypertension. In addition, more attention has been given to load adaptability metrics of the right heart; these simplified indices, however, still face challenges from a conceptual point of view. The emergence of novel MRI sequences, such as native T1 mapping, allows better detection and quantification of myocardial fibrosis and could allow better prediction of postsurgical recovery of the right heart. Other advances in MRI include four-dimensional flow imaging, which may be particularly useful in congenital heart disease or for the detection of early stages of pulmonary vascular disease.

SUMMARY

The review will place the recent developments in right heart imaging in the context of clinical care and research.