1
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Koerber DM, Katz JN, Bohula E, Park JG, Dodson MW, Gerber DA, Hillerson D, Liu S, Pierce MJ, Prasad R, Rose SW, Sanchez PA, Shaw J, Wang J, Jentzer JC, Kristin Newby L, Daniels LB, Morrow DA, van Diepen S. Variation in risk-adjusted cardiac intensive care unit (CICU) length of stay and the association with in-hospital mortality: An analysis from the Critical Care Cardiology Trials Network (CCCTN) registry. Am Heart J 2024; 271:28-37. [PMID: 38369218 DOI: 10.1016/j.ahj.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Previous studies have suggested that there is wide variability in cardiac intensive care unit (CICU) length of stay (LOS); however, these studies are limited by the absence of detailed risk assessment at the time of admission. Thus, we evaluated inter-hospital differences in CICU LOS, and the association between LOS and in-hospital mortality. METHODS Using data from the Critical Care Cardiology Trials Network (CCCTN) registry, we included 22,862 admissions between 2017 and 2022 from 35 primarily tertiary and quaternary CICUs that captured consecutive admissions in annual 2-month snapshots. The primary analysis compared inter-hospital differences in CICU LOS, as well as the association between CICU LOS and all-cause in-hospital mortality using a Fine and Gray competing risk model. RESULTS The overall median CICU LOS was 2.2 (1.1-4.8) days, and the median hospital LOS was 5.9 (2.8-12.3) days. Admissions in the longest tertile of LOS tended to be younger with higher rates of pre-existing comorbidities, and had higher Sequential Organ Failure Assessment (SOFA) scores, as well as higher rates of mechanical ventilation, intravenous vasopressor use, mechanical circulatory support, and renal replacement therapy. Unadjusted all-cause in-hospital mortality was 9.3%, 6.7%, and 13.4% in the lowest, intermediate, and highest CICU LOS tertiles. In a competing risk analysis, individual patient CICU LOS was correlated (r2 = 0.31) with a higher risk of 30-day in-hospital mortality. The relationship remained significant in admissions with heart failure, ST-elevation myocardial infarction and non-ST segment elevation myocardial infarction. CONCLUSIONS In a large registry of academic CICUs, we observed significant variation in CICU LOS and report that LOS is independently associated with all-cause in-hospital mortality. These findings could potentially be used to improve CICU resource utilization planning and refine risk prognostication in critically ill cardiovascular patients.
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Affiliation(s)
- Daniel M Koerber
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Erin Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Mark W Dodson
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Daniel A Gerber
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Dustin Hillerson
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Shuangbo Liu
- Max Rady College of Medicine, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Matthew J Pierce
- North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | | | - Scott W Rose
- Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Pablo A Sanchez
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jeffrey Shaw
- Division of Cardiology, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, Durham, NC
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA
| | - 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, MA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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2
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Mendiola Pla M, Chiang Y, Nicoara A, Poehlein E, Green CL, Gross R, Bryner BS, Schroder JN, Daneshmand MA, Russell SD, DeVore AD, Patel CB, Katz JN, Milano CA, Bishawi M. Surgical Treatment of Tricuspid Valve Regurgitation in Patients Undergoing Left Ventricular Assist Device Implantation: Interim analysis of the TVVAD trial. J Thorac Cardiovasc Surg 2024; 167:1810-1820.e2. [PMID: 36639288 PMCID: PMC10185708 DOI: 10.1016/j.jtcvs.2022.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/11/2022] [Accepted: 10/29/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Right heart failure remains a serious complication of left ventricular assist device therapy. Many patients presenting for left ventricular assist device implantation have significant tricuspid regurgitation. It remains unknown whether concurrent tricuspid valve surgery reduces postoperative right heart failure. The primary aim was to identify whether concurrent tricuspid valve surgery reduced the incidence of moderate or severe right heart failure within the first 6 months after left ventricular assist device implantation. METHODS Patients with moderate or severe tricuspid regurgitation on preoperative echocardiography were randomized to left ventricular assist device implantation alone (no tricuspid valve surgery) or with concurrent tricuspid valve surgery. Randomization was stratified by preoperative right ventricular dysfunction. The primary end point was the frequency of moderate or severe right heart failure within 6 months after surgery. RESULTS This report describes a planned interim analysis of the first 60 randomized patients. The tricuspid valve surgery group (n = 32) had mild or no tricuspid regurgitation more frequently on follow-up echocardiography studies compared with the no tricuspid valve surgery group (n = 28). However, at 6 months, the incidence of moderate and severe right heart failure was similar in each group (tricuspid valve surgery: 46.9% vs no tricuspid valve surgery: 50%, P = .81). There was no significant difference in postoperative mortality or requirement for right ventricular assist device between the groups. There were also no significant differences in secondary end points of functional status and adverse events. CONCLUSIONS The presence of significant tricuspid regurgitation before left ventricular assist device is associated with a high incidence of right heart failure within the first 6 months after surgery. Tricuspid valve surgery was successful in reducing postimplant tricuspid regurgitation compared with no tricuspid valve surgery but was not associated with a lower incidence of right heart failure.
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Affiliation(s)
| | - Yuting Chiang
- Division of Cardiothoracic Surgery, Columbia University, New York, NY
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center
| | - Emily Poehlein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Ryan Gross
- Division of Cardiothoracic Surgery, Duke University Medical Center
| | | | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center
| | | | | | - Adam D DeVore
- Division of Cardiology, Duke University Medical Center
| | | | - Jason N Katz
- Division of Cardiology, Duke University Medical Center
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center.
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Duke University Medical Center
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3
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Senman B, Pierce J, Kittipibul V, Barnes S, Whitacre M, Katz JN. Safety of Chest Compressions in Patients With a Durable Left Ventricular Assist Device. JACC Heart Fail 2024:S2213-1779(24)00255-5. [PMID: 38661587 DOI: 10.1016/j.jchf.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/20/2024] [Accepted: 03/06/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Balimkiz Senman
- Duke University Medical Center, Durham, North Carolina, USA.
| | - Jacob Pierce
- Duke University Medical Center, Durham, North Carolina, USA
| | | | | | | | - Jason N Katz
- New York University Grossman School of Medicine and Bellevue Hospital Center, New York, New York, USA
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4
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Patel SM, Berg DD, Bohula EA, Baird-Zars VM, Barsness GW, Chaudhry SP, Chonde MD, Cooper HA, Ginder C, Jentzer JC, Kontos MC, Miller PE, Newby LK, O'Brien CG, Park JG, Pierce MJ, Pisani BA, Potter BJ, Shah KS, Teuteberg JJ, Katz JN, van Diepen S, Morrow DA. Early Serial Assessment of Aggregate Vasoactive Support and Mortality in Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry. Circ Heart Fail 2024. [PMID: 38587438 DOI: 10.1161/circheartfailure.124.011736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
Background: Associations of early changes in vasoactive support with cardiogenic shock (CS) mortality remain incompletely defined. Methods: The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units (CICUs). Patients admitted with CS (2018-2023) had vasoactive dosing assessed at 4 and 24 hours (h) from CICU admission and quantified by the vasoactive-inotropic score (VIS). Prognostic associations of VIS at both timepoints, as well as change in VIS from 4h to 24h, were examined. Interaction testing was performed by mechanical circulatory support (MCS) status. Results: Among 3,665 patients, 82% had a change in VIS <10, with 7% and 11% having a ≥10point increase and decrease from 4h to 24h, respectively. The 4h and 24h VIS were each associated with CICU mortality (13%- 45% and 11%-73% for VIS <10 to ≥40, respectively; ptrend <0.0001 for each). Stratifying by the 4h VIS, changes in VIS from 4h to 24h had a graded association with mortality, ranging from a 2-to->4-fold difference in mortality comparing those with a ≥10-point increase to a ≥10-point decrease in VIS (p-trend <0.0001). The change in VIS alone provided good discrimination of CICU mortality (C-statistic 0.72 [95% CI 0.70-0.75]), and improved discrimination of the 24h SOFA score (0.76 [95% CI 0.74-0.78] from 0.72 [95% CI 0.69-0.74]) and the clinician-assessed SCAI stage (0.77 [95% CI 0.75-0.79] from 0.72 [95% CI 0.70-0.74]). Although present in both groups, the mortality risk associated with VIS was attenuated in patients managed with vs. without MCS (OR per 10-point higher 24h VIS: 1.36 [1.23-1.49] vs. 1.84 [1.69-2.01]; p-interaction<0.0001). Conclusions: Early changes in the magnitude of vasoactive support in CS are associated with a gradient of risk for mortality. These data suggest that early VIS trajectory may improve CS prognostication, with potential to be leveraged for clinical decision-making and research applications in CS.
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Affiliation(s)
- Siddharth M Patel
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David D Berg
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Vivan M Baird-Zars
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Meshe D Chonde
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Howard A Cooper
- Westchester Medical Center, New York Medical College, Valhalla, NY
| | - Curtis Ginder
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael C Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University, New Haven, CT
| | - L Kristin Newby
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Matthew J Pierce
- Department of Cardiology, Northshore University Hospital, Northwell Health, Manhasset, NY
| | - Barbara A Pisani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Brian J Potter
- Cardiology Service, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM) Research Center and Cardiovascular Center, Montreal, Quebec, Canada
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, UT
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jason N Katz
- Division of Cardiovascular Medicine, Department of Medicine, New York University School of Medicine, New York, NY
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Blumer V, Kanwar MK, Barnett CF, Cowger JA, Damluji AA, Farr M, Goodlin SJ, Katz JN, McIlvennan CK, Sinha SS, Wang TY. Cardiogenic Shock in Older Adults: A Focus on Age-Associated Risks and Approach to Management: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1051-e1065. [PMID: 38406869 DOI: 10.1161/cir.0000000000001214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Cardiogenic shock continues to portend poor outcomes, conferring short-term mortality rates of 30% to 50% despite recent scientific advances. Age is a nonmodifiable risk factor for mortality in patients with cardiogenic shock and is often considered in the decision-making process for eligibility for various therapies. Older adults have been largely excluded from analyses of therapeutic options in patients with cardiogenic shock. As a result, despite the association of advanced age with worse outcomes, focused strategies in the assessment and management of cardiogenic shock in this high-risk and growing population are lacking. Individual programs oftentimes develop upper age limits for various interventional strategies for their patients, including heart transplantation and durable left ventricular assist devices. However, age as a lone parameter should not be used to guide individual patient management decisions in cardiogenic shock. In the assessment of risk in older adults with cardiogenic shock, a comprehensive, interdisciplinary approach is central to developing best practices. In this American Heart Association scientific statement, we aim to summarize our contemporary understanding of the epidemiology, risk assessment, and in-hospital approach to management of cardiogenic shock, with a unique focus on older adults.
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6
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Alviar CL, Li BK, Keller NM, Bohula-May E, Barnett C, Berg DD, Burke JA, Chaudhry SP, Daniels LB, DeFilippis AP, Gerber D, Horowitz J, Jentzer JC, Katrapati P, Keeley E, Lawler PR, Park JG, Sinha SS, Snell J, Solomon MA, Teuteberg J, Katz JN, van Diepen S, Morrow DA. Prognostic performance of the IABP-SHOCK II Risk Score among cardiogenic shock subtypes in the critical care cardiology trials network registry. Am Heart J 2024; 270:1-12. [PMID: 38190931 PMCID: PMC11032171 DOI: 10.1016/j.ahj.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Risk stratification has potential to guide triage and decision-making in cardiogenic shock (CS). We assessed the prognostic performance of the IABP-SHOCK II score, derived in Europe for acute myocardial infarct-related CS (AMI-CS), in a contemporary North American cohort, including different CS phenotypes. METHODS The critical care cardiology trials network (CCCTN) coordinated by the TIMI study group is a multicenter network of cardiac intensive care units (CICU). Participating centers annually contribute ≥2 months of consecutive medical CICU admissions. The IABP-SHOCK II risk score includes age > 73 years, prior stroke, admission glucose > 191 mg/dl, creatinine > 1.5 mg/dl, lactate > 5 mmol/l, and post-PCI TIMI flow grade < 3. We assessed the risk score across various CS etiologies. RESULTS Of 17,852 medical CICU admissions 5,340 patients across 35 sites were admitted with CS. In patients with AMI-CS (n = 912), the IABP-SHOCK II score predicted a >3-fold gradient in in-hospital mortality (low risk = 26.5%, intermediate risk = 52.2%, high risk = 77.5%, P < .0001; c-statistic = 0.67; Hosmer-Lemeshow P = .79). The score showed a similar gradient of in-hospital mortality in patients with non-AMI-related CS (n = 2,517, P < .0001) and mixed shock (n = 923, P < .001), as well as in left ventricular (<0.0001), right ventricular (P = .0163) or biventricular (<0.0001) CS. The correlation between the IABP-SHOCK II score and SOFA was moderate (r2 = 0.17) and the IABP-SHOCK II score revealed a significant risk gradient within each SCAI stage. CONCLUSIONS In an unselected international multicenter registry of patients admitted with CS, the IABP- SHOCK II score only moderately predicted in-hospital mortality in a broad population of CS regardless of etiology or irrespective of right, left, or bi-ventricular involvement.
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Affiliation(s)
- Carlos L Alviar
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY;.
| | - Boyangzi K Li
- Division of Cardiology, University of Miami, Miami, FL
| | - Norma M Keller
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY
| | - Erin Bohula-May
- Levine Cardiac Intensive Care Unit, Brigham and Women's Hospital, Boston, MA
| | - Christopher Barnett
- Division of Cardiology, University of California San Francisco, San Francisco, CA
| | - David D Berg
- Levine Cardiac Intensive Care Unit, Brigham and Women's Hospital, Boston, MA
| | - James A Burke
- Division of Cardiology, Lehigh Valley Health Network, Allentown, PA
| | | | - Lori B Daniels
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA
| | | | - Daniel Gerber
- Division of Cardiology, Stanford University, Stanford, CA
| | - James Horowitz
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY
| | - Jacob C Jentzer
- Division of Cardiovascular Medicine, Mayo Clinic, Minnesota, CA
| | | | - Ellen Keeley
- Division of Cardiology, University of Florida, Gainesville, FL
| | - Patrick R Lawler
- McGill University Health Centre, Montreal, Quebec, Canada;; Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, Brigham and Women's Hospital, Boston, MA
| | - Shashank S Sinha
- Inova Fairfax Medical Campus, Inova Heart and Vascular Institute, Falls Church, VA
| | - Jeffrey Snell
- Division of Cardiology, Rush University, Chicago, IL
| | - 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
| | | | - Jason N Katz
- The Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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7
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Senman B, Jentzer JC, Barnett CF, Bartos JA, Berg DD, Chih S, Drakos SG, Dudzinski DM, Elliott A, Gage A, Horowitz JM, Miller PE, Sinha SS, Tehrani BN, Yuriditsky E, Vallabhajosyula S, Katz JN. Need for a Cardiogenic Shock Team Collaborative-Promoting a Team-Based Model of Care to Improve Outcomes and Identify Best Practices. J Am Heart Assoc 2024; 13:e031979. [PMID: 38456417 PMCID: PMC11009990 DOI: 10.1161/jaha.123.031979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024]
Abstract
Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.
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Affiliation(s)
| | | | - Christopher F. Barnett
- Division of Cardiology, Department of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Jason A. Bartos
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - David D. Berg
- Division of Cardiovascular MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMAUSA
| | | | - Stavros G. Drakos
- Department of Medicine, Division of Cardiovascular Medicine and Nora Eccles Harrison Cardiovascular Research and Training InstituteUniversity of Utah School of MedicineSalt Lake CityUTUSA
| | | | - Andrea Elliott
- Department of Medicine‐Cardiovascular DivisionUniversity of MinnesotaMinneapolisMNUSA
| | - Ann Gage
- Department of Cardiovascular MedicineCentennial Medical CenterNashvilleTNUSA
| | - James M. Horowitz
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of MedicineNew HavenCTUSA
| | - Shashank S. Sinha
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Behnam N. Tehrani
- Inova Schar Heart and Vascular, Inova Fairfax Medical CampusFalls ChurchVAUSA
| | - Eugene Yuriditsky
- Division of CardiologyNew York University Grossman School of MedicineNew YorkNYUSA
| | - Saraschandra Vallabhajosyula
- Division of Cardiology, Department of MedicineWarren Alpert Medical School of Brown University and Lifespan Cardiovascular InstituteProvidenceRIUSA
| | - Jason N. Katz
- Division of CardiologyNYU Grossman School of Medicine & Bellevue Hospital CenterNew YorkNYUSA
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8
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Papolos AI, Kenigsberg BB, Singam NSV, Berg DD, Guo J, Bohula EA, Katz JN, Diepen SVAN, Morrow DA. Pulmonary Artery Diastolic Pressure as a Surrogate for Pulmonary Capillary Wedge Pressure in Cardiogenic Shock. J Card Fail 2024:S1071-9164(24)00088-5. [PMID: 38513886 DOI: 10.1016/j.cardfail.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/06/2024] [Accepted: 02/16/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND It is common for clinicians to use the pulmonary artery diastolic pressure (PADP) as a surrogate for the pulmonary capillary wedge pressure (PCWP). Here, we determine the validity of this relationship in patients with various phenotypes of cardiogenic shock (CS). METHODS AND RESULTS In this analysis of the Critical Care Cardiology Trials Network registry, we identified 1225 people admitted with CS who received pulmonary artery catheters. Linear regression, Bland-Altman and receiver operator characteristic analyses were performed to determine the strength of the association between PADP and PCWP in patients with left-, right-, biventricular, and other non-myocardia phenotypes of CS (eg, arrhythmia, valvular stenosis, tamponade). There was a moderately strong correlation between PADP and PCWP in the total population (r = 0.64, n = 1225) and in each CS phenotype, except for right ventricular CS, for which the correlation was weak (r = 0.43, n = 71). Additionally, we found that a PADP ≥ 24 mmHg can be used to infer a PCWP ≥ 18 mmHg with ≥ 90% confidence in all but the right ventricular CS phenotype. CONCLUSIONS This analysis validates the practice of using PADP as a surrogate for PCWP in most patients with CS; however, it should generally be avoided in cases of right ventricular-predominant CS.
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Affiliation(s)
- Alexander I Papolos
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
| | - Benjamin B Kenigsberg
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Narayana Sarma V Singam
- Department of Critical Care and Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jianping Guo
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason N Katz
- Department of Medicine, Division of Cardiology, New York University, New York, NY, USA
| | - Sean VAN Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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9
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Vallabhajosyula S, Mehta A, Bansal M, Jentzer JC, Applefeld WN, Sinha SS, Geller BJ, Gage AE, Rose SW, Barnett CF, Katz JN, Morrow DA, Roswell RO, Solomon MA. Training Paradigms in Critical Care Cardiology: A Scoping Review of Current Literature. JACC Adv 2024; 3:100850. [PMID: 38352139 PMCID: PMC10861182 DOI: 10.1016/j.jacadv.2024.100850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Background Over the past decade there has been increasing interest in critical care medicine (CCM) training for cardiovascular medicine (CV) physicians either in isolation (separate programs in either order [CV/CCM], integrated critical care cardiology [CCC] training) or hybrid training with interventional cardiology (IC)/heart failure/transplant (HF) with targeted CCC training. Objective To review the contemporary landscape of CV/CCM, CCC, and hybrid training. Methods We reviewed the literature from 2000-2022 for publications discussing training in any combination of internal medicine CV/CCM, CCC, and hybrid training. Information regarding training paradigms, scope of practice and training, duration, sequence, and milestones was collected. Results Of the 2,236 unique citations, 20 articles were included. A majority were opinion/editorial articles whereas two were surveys. The training pathways were classified into - (i) specialty training in both CV (3 years) and CCM (1-2 years) leading to dual American Board of Internal Medicine (ABIM) board certification, or (ii) base specialty training in CV with competencies in IC, HF or CCC leading to a non-ABIM certificate. Total fellowship duration varied between 4-7 years after a three-year internal medicine residency. While multiple articles commented on the ability to integrate the fellowship training pathways into a holistic and seamless training curriculum, few have highlighted how this may be achieved to meet competencies and standards. Conclusions In 20 articles describing CV/CCM, CCC, and hybrid training, there remains significant heterogeneity on the standardized training paradigms to meet training competencies and board certifications, highlighting an unmet need to define CCC competencies.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
- Lifespan Cardiovascular Institute, Providence, RI
| | - Aryan Mehta
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Mridul Bansal
- Department of Medicine, East Carolina University Brody School of Medicine, Greenville, NC
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Willard N Applefeld
- Division of Cardiovascular Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Shashank S Sinha
- Inova Fairfax Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA
| | - Bram J Geller
- Department of Cardiovascular Medicine and Department of Cardiovascular Critical Care Services, Maine Medical Center, Portland, ME
| | - Ann E Gage
- Centennial Heart, Centennial Medical Center, Nashville, TN
| | - Scott W Rose
- Division of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Jason N Katz
- Division of Cardiovascular Medicine, Department of Medicine, New York University School of Medicine, New York, NY
| | - David A Morrow
- Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Robert O Roswell
- Section of Cardiovascular Medicine, Department of Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY
| | - Michael A Solomon
- Department of Critical Care Medicine, Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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Sephien A, Dayto DC, Reljic T, Prida X, Joly JM, Tavares M, Katz JN, Kumar A. Efficacy of Intravenous Iron in Patients with Heart Failure with Reduced Ejection Fraction and Iron Deficiency: A Systematic Review and Meta-Analysis of Randomized Control Trials. Am J Cardiovasc Drugs 2024; 24:285-302. [PMID: 38519808 DOI: 10.1007/s40256-024-00635-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND The European Society of Cardiology (ESC) provided a focused update to the 2021 Guideline for the Management of Heart Failure, now providing a 1A recommendation for intravenous iron in patients with heart failure with reduced ejection fraction (HFrEF) and iron deficiency (ID). However, the findings from randomized controlled trials (RCT) are mixed. This systematic review of RCTs aims to provide an update and synthesize the evidence addressing the association of intravenous iron with patient-based outcomes in patients with HFrEF and ID. METHODS Any RCT evaluating the effect of intravenous iron in patients with HFrEF and ID was eligible for inclusion. A complete search of the EMBASE and PubMed databases was conducted from inception until 15 September 2023. The primary outcome was the composite of the quality of life (QoL) questionnaires, while the secondary outcomes included first heart failure (HF) hospitalizations and all-cause mortality. Data extraction was performed independently by two reviewers. Data were pooled using a random-effects model. RESULTS Of the 1035 references, 15 RCTs enrolling 6649 patients were included in this study. Intravenous iron was associated with significant improvement in the composite of QoL (standardized mean difference - 1.36, 95% confidence interval [CI] - 2.24 to - 0.48; p = 0.002), a significant reduction in first HF hospitalizations (hazard ratio [HR] 0.73, 95% CI 0.56-0.95; p = 0.02), and with no change in all-cause mortality (HR 0.90, 95% CI 0.79-1.03; p = 0.12). The certainty of the evidence ranged from moderate to very low. CONCLUSION Intravenous iron is possibly associated with improved QoL and reduced HF hospitalizations, without impacting all-cause mortality. These findings not only support the use of intravenous iron in patients with HFrEF but also emphasize the need for well-designed and executed RCTs with granular outcome reporting and powered sufficiently to address the impact of intravenous iron on mortality in patients with HFrEF and ID. REGISTRATION PROSPERO identifier number CRD42023389.
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Affiliation(s)
- Andrew Sephien
- Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Denisse Camille Dayto
- Department of Internal Medicine, HCA Healthcare/USF Morsani GME Consortium: HCA Florida Citrus Hospital, Inverness, FL, USA
| | - Tea Reljic
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Xavier Prida
- Division of Cardiovascular Sciences, University of South Florida, Tampa, FL, USA
| | - Joanna M Joly
- Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplantation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew Tavares
- Department of Internal Medicine, HCA Healthcare/USF Morsani GME Consortium: HCA Florida Citrus Hospital, Inverness, FL, USA
| | - Jason N Katz
- Division of Cardiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Ambuj Kumar
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida, Tampa, FL, USA
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11
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Berg DD, Singal S, Palazzolo M, Baird-Zars VM, Bofarrag F, Bohula EA, Chaudhry SP, Dodson MW, Hillerson D, Lawler PR, Liu S, O'Brien CG, Pisani BA, Racharla L, Roswell RO, Shah KS, Solomon MA, Sridharan L, Thompson AD, Diepen SVAN, Katz JN, Morrow DA. Modes of Death in Patients with Cardiogenic Shock in the Cardiac Intensive Care Unit: A Report from the Critical Care Cardiology Trials Network. J Card Fail 2024:S1071-9164(24)00042-3. [PMID: 38387758 DOI: 10.1016/j.cardfail.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 01/26/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND There are limited data on how patients with cardiogenic shock (CS) die. METHODS The Critical Care Cardiology Trials Network is a research network of cardiac intensive care units coordinated by the Thrombolysis In Myocardial Infarction (TIMI) Study Group (Boston, MA). Using standardized definitions, site investigators classified direct modes of in-hospital death for CS admissions (October 2021 to September 2022). Mutually exclusive categories included 4 modes of cardiovascular death and 4 modes of noncardiovascular death. Subgroups defined by CS type, preceding cardiac arrest (CA), use of temporary mechanical circulatory support (tMCS), and transition to comfort measures were evaluated. RESULTS Among 1068 CS cases, 337 (31.6%) died during the index hospitalization. Overall, the mode of death was cardiovascular in 82.2%. Persistent CS was the dominant specific mode of death (66.5%), followed by arrhythmia (12.8%), anoxic brain injury (6.2%), and respiratory failure (4.5%). Patients with preceding CA were more likely to die from anoxic brain injury (17.1% vs 0.9%; P < .001) or arrhythmia (21.6% vs 8.4%; P < .001). Patients managed with tMCS were more likely to die from persistent shock (P < .01), both cardiogenic (73.5% vs 62.0%) and noncardiogenic (6.1% vs 2.9%). CONCLUSIONS Most deaths in CS are related to direct cardiovascular causes, particularly persistent CS. However, there is important heterogeneity across subgroups defined by preceding CA and the use of tMCS.
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Affiliation(s)
- David D Berg
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Sachit Singal
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Palazzolo
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fadel Bofarrag
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Mark W Dodson
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - Dustin Hillerson
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Shuangbo Liu
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Barbara A Pisani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | | | - Robert O Roswell
- Northwell, Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell. New Hyde Park, NY
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, Blood Institute of the National Institutes of Health, Bethesda, Maryland
| | - Lakshmi Sridharan
- Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Andrea D Thompson
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sean VAN Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jason N Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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12
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Kruser JM, Ashana DC, Courtright KR, Kross EK, Neville TH, Rubin E, Schenker Y, Sullivan DR, Thornton JD, Viglianti EM, Costa DK, Creutzfeldt CJ, Detsky ME, Engel HJ, Grover N, Hope AA, Katz JN, Kohn R, Miller AG, Nabozny MJ, Nelson JE, Shanawani H, Stevens JP, Turnbull AE, Weiss CH, Wirpsa MJ, Cox CE. Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2024; 21:187-199. [PMID: 38063572 PMCID: PMC10848901 DOI: 10.1513/annalsats.202310-925st] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.
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13
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Drazner MH, Ambardekar AV, Berlacher K, Blumer V, Chatur S, Cheng R, Cheng RK, Grandin EW, Gorodeski EZ, Kataria R, Katz JN, Kittleson MM, Krishnamoorthy A, Lala A, Lenneman AJ, Lohr NL, Margulies KB, Mentz RJ, Reza N, Wilcox J, Youmans QR, Zieroth S, Teerlink JR. The HFSA Advanced Heart Failure and Transplant Cardiology Fellowship Consensus Conference. J Card Fail 2024; 30:391-398. [PMID: 37806488 DOI: 10.1016/j.cardfail.2023.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/22/2023] [Accepted: 09/23/2023] [Indexed: 10/10/2023]
Abstract
There is waning interest among cardiology trainees in pursuing an Advanced Heart Failure/Transplant Cardiology (AHFTC) fellowship as evidenced by fewer applicants in the National Resident Matching Program match to this specialty. This trend has generated considerable attention across the heart failure community. In response, the Heart Failure Society of America convened the AHFTC Fellowship Task Force with a charge to develop strategies to increase the value proposition of an AHFTC fellowship. Subsequently, the HFSA sponsored the AHFTC Fellowship Consensus Conference April 26-27, 2023. Before the conference, interviews of 44 expert stakeholders diverse across geography, site of practice (traditional academic medical center or other centers), specialty/area of expertise, sex, and stage of career were conducted virtually. Based on these interviews, potential solutions to address the declining interest in AHFTC fellowship were categorized into five themes: (1) alternative training pathways, (2) regulatory and compensation, (3) educational improvements, (4) exposure and marketing for pipeline development, and (5) quality of life and mental health. These themes provided structure to the deliberations of the AHFTC Fellowship Consensus Conference. The recommendations from the Consensus Conference were subsequently presented to the HFSA Board of Directors to inform strategic plans and interventions. The HFSA Board of Directors later reviewed and approved submission of this document. The purpose of this communication is to provide the HF community with an update summarizing the processes used and concepts that emerged from the work of the HFSA AHFTC Fellowship Task Force and Consensus Conference.
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Affiliation(s)
- Mark H Drazner
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Amrut V Ambardekar
- Department of Medicine, Division of Cardiology; University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kathryn Berlacher
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vanessa Blumer
- Inova Schar and Vascular Institute, Falls Church, Virginia
| | - Safia Chatur
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard Cheng
- Division of Cardiology, Department of Internal Medicine; University of California San Francisco, San Francisco, California
| | - Richard K Cheng
- Division of Cardiology, University of Washington, Seattle, Washington
| | - E Wilson Grandin
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Eiran Z Gorodeski
- Harrington Heart & Vascular Institute, University Hospitals, and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Rachna Kataria
- Department of Cardiology, Lifespan Cardiovascular Institute, Brown University, Providence, Rhode Island
| | - Jason N Katz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute-Cedars Sinai Medical Center, Los Angeles, California
| | | | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute & Department of Population Health Science & Policy at Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrew J Lenneman
- Division of Cardiovascular Disease; University of Alabama at Birmingham, Birmingham, Alabama
| | - Nicole L Lohr
- Division of Cardiovascular Disease; University of Alabama at Birmingham, Birmingham, Alabama
| | - Kenneth B Margulies
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jane Wilcox
- Division of Cardiovascular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Quentin R Youmans
- Division of Cardiovascular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, California
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14
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Sephien A, Dayto DC, Reljic T, Katz JN, Lenneman AJ, Prida X, Joly JM, Kumar A. Efficacy of Decision Aids in The Use of Left Ventricular Assist Device in Patients With Advanced Heart Failure: A Systematic Review and Meta-Analysis of Randomized Control Trials. Am J Cardiol 2024; 211:255-258. [PMID: 37979637 DOI: 10.1016/j.amjcard.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/02/2023] [Accepted: 11/11/2023] [Indexed: 11/20/2023]
Abstract
Although left ventricular assist device (LVAD) implantation can improve survival in patients with end-stage heart failure, it is not without risk. Numerous complications are possible, and durable support requires substantial lifestyle changes. The use of various knowledge-assessment tools may allow for more informed patient decisions. To synthesize the totality of the evidence, we conducted a systematic review and meta-analysis to summarize the efficacy of decision aid (DA) use in patients with advanced heart failure who are eligible for LVAD. Any randomized controlled trial (RCT) evaluating the efficacy of DAs in patients considering LVAD was eligible for inclusion. A complete search of EMBASE and PubMed was conducted from the start until June 8, 2023. The primary outcome was patients' LVAD knowledge. Data extraction was performed independently by 2 reviewers. Data were pooled using a random-effects model. Of the 575 references, 2 RCTs randomizing 490 patients were included in this study. DAs were associated with no significant change in LVAD knowledge (standardized mean difference 0.07, 95% confidence interval -0.24 to 0.39, p = 0.64) or decisional conflict (mean difference -1.48, 95% confidence interval -5.28 to 2.32, p = 0.45). The certainty of the evidence ranged from moderate to very low. The use of DAs in LVAD-eligible patients with advanced heart failure resulted in no difference in patients' knowledge of LVAD after LVAD education. The findings from this study will aid in the power analysis of a well-designed RCT to evaluate and encourage further investigation into the efficacy and relevance of DAs in preparing patients for a life with LVAD.
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Affiliation(s)
- Andrew Sephien
- Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplantation, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Denisse Camille Dayto
- Department of Internal Medicine, HCA Healthcare/USF Morsani GME Consortium: HCA Florida Citrus Hospital, Inverness, Florida
| | - Tea Reljic
- Department of Internal Medicine, Research Methodology and Biostatistics Core, Office of Research
| | - Jason N Katz
- Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Andrew J Lenneman
- Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplantation, University of Alabama at Birmingham, Birmingham, Alabama
| | - Xavier Prida
- Division of Cardiovascular Sciences, University of South Florida, Tampa, Florida
| | - Joanna M Joly
- Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplantation, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ambuj Kumar
- Department of Internal Medicine, Research Methodology and Biostatistics Core, Office of Research
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15
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Cox CE, Ashana DC, Riley IL, Olsen MK, Casarett D, Haines KL, O’Keefe YA, Al-Hegelan M, Harrison RW, Naglee C, Katz JN, Yang H, Pratt EH, Gu J, Dempsey K, Docherty SL, Johnson KS. Mobile Application-Based Communication Facilitation Platform for Family Members of Critically Ill Patients: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2349666. [PMID: 38175648 PMCID: PMC10767607 DOI: 10.1001/jamanetworkopen.2023.49666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/13/2023] [Indexed: 01/05/2024] Open
Abstract
Importance Unmet and racially disparate palliative care needs are common in intensive care unit (ICU) settings. Objective To test the effect of a primary palliative care intervention vs usual care control both overall and by family member race. Design, Setting, and Participants This cluster randomized clinical trial was conducted at 6 adult medical and surgical ICUs in 2 academic and community hospitals in North Carolina between April 2019 and May 2022 with physician-level randomization and sequential clusters of 2 Black patient-family member dyads and 2 White patient-family member dyads enrolled under each physician. Eligible participants included consecutive patients receiving mechanical ventilation, their family members, and their attending ICU physicians. Data analysis was conducted from June 2022 to May 2023. Intervention A mobile application (ICUconnect) that displayed family-reported needs over time and provided ICU attending physicians with automated timeline-driven communication advice on how to address individual needs. Main Outcomes and Measures The primary outcome was change in the family-reported Needs at the End-of-Life Screening Tool (NEST; range 0-130, with higher scores reflecting greater need) score between study days 1 and 3. Secondary outcomes included family-reported quality of communication and symptoms of depression, anxiety, and posttraumatic stress disorder at 3 months. Results A total of 111 (51% of those approached) family members (mean [SD] age, 51 [15] years; 96 women [86%]; 15 men [14%]; 47 Black family members [42%]; 64 White family members [58%]) and 111 patients (mean [SD] age, 55 [16] years; 66 male patients [59%]; 45 Black patients [41%]; 65 White patients [59%]; 1 American Indian or Alaska Native patient [1%]) were enrolled under 37 physicians randomized to intervention (19 physicians and 55 patient-family member dyads) or control (18 physicians and 56 patient-family member dyads). Compared with control, there was greater improvement in NEST scores among intervention recipients between baseline and both day 3 (estimated mean difference, -6.6 points; 95% CI, -11.9 to -1.3 points; P = .01) and day 7 (estimated mean difference, -5.4 points; 95% CI, -10.7 to 0.0 points; P = .05). There were no treatment group differences at 3 months in psychological distress symptoms. White family members experienced a greater reduction in NEST scores compared with Black family members at day 3 (estimated mean difference, -12.5 points; 95% CI, -18.9 to -6.1 points; P < .001 vs estimated mean difference, -0.3 points; 95% CI, -9.3 to 8.8 points; P = .96) and day 7 (estimated mean difference, -9.5 points; 95% CI, -16.1 to -3.0 points; P = .005 vs estimated mean difference, -1.4 points; 95% CI, -10.7 to 7.8; P = .76). Conclusions and Relevance In this study of ICU patients and family members, a primary palliative care intervention using a mobile application reduced unmet palliative care needs compared with usual care without an effect on psychological distress symptoms at 3 months; there was a greater intervention effect among White family members compared with Black family members. These findings suggest that a mobile application-based intervention is a promising primary palliative care intervention for ICU clinicians that directly addresses the limited supply of palliative care specialists. Trial Registration ClinicalTrials.gov Identifier: NCT03506438.
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Affiliation(s)
- Christopher E. Cox
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Deepshikha C. Ashana
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Isaretta L. Riley
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Maren K. Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - David Casarett
- Department of Medicine, Section of Palliative Care and Hospice Medicine, Duke University, Durham, North Carolina
| | - Krista L. Haines
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, North Carolina
| | | | - Mashael Al-Hegelan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Robert W. Harrison
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Jason N. Katz
- Department of Medicine, Division of Cardiology, Duke University, Durham, North Carolina
| | - Hongqiu Yang
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Elias H. Pratt
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Jessie Gu
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | - Katelyn Dempsey
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, North Carolina
| | | | - Kimberly S. Johnson
- Department of Medicine, Division of Geriatrics, Duke University, Durham, North Carolina
- Geriatrics Research, Education, and Clinical Center, Veterans Affairs Health Care System, Durham, North Carolina
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Lessing JK, Kram SJ, Levy JH, Grecu LM, Katz JN. Droxidopa or Atomoxetine for Refractory Hypotension in Critically Ill Cardiothoracic Surgery Patients. J Cardiothorac Vasc Anesth 2024; 38:155-161. [PMID: 37838507 DOI: 10.1053/j.jvca.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE To evaluate the effects of droxidopa or atomoxetine on intravenous (IV) vasoactive agent discontinuation in cardiothoracic intensive care unit (ICU) patients with hypotension refractory to midodrine. DESIGN Single-center, retrospective cohort study. SETTING Tertiary- and quaternary-care university teaching hospital. PARTICIPANTS Included patients who received at least 4 consecutive doses of droxidopa or atomoxetine and remained on concurrent midodrine. Patients were excluded if they received study medication before admission, had clinical deterioration after study medication initiation requiring additional vasoactives/escalation of IV vasoactive dosage for at least 12 hours, had a diagnosis of hepatorenal syndrome, were prisoners, or were pregnant. INTERVENTIONS Droxidopa, atomoxetine, or both. MEASUREMENTS AND MAIN RESULTS The primary endpoint was time to discontinuation of IV vasoactive agents after initiation of study medication, analyzed using a Kaplan-Meier estimate with the Wilcoxon method, censoring death within 24 hours of the last dose of study medication. No adjustment for repetitive analyses was made, as the analysis was hypothesis-generating. Of the 72 charts reviewed, 45 patients met inclusion criteria (18 atomoxetine, 17 droxidopa, and 10 both). There were no differences in median time to discontinuation of IV vasoactive agents (21.9 days v 8.0 days v 13.9 days, respectively; p = 0.259) or ICU or hospital length of stay between groups. A higher percentage of patients who survived to hospital discharge received both study medications or droxidopa alone (90% v 76.5%) than atomoxetine alone (44.4%, p = 0.028). CONCLUSIONS Droxidopa and atomoxetine are oral vasoactive agents with potential mechanisms to facilitate IV vasopressor weaning for patients in the ICU with hypotension refractory to midodrine, but further prospective research is needed.
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Affiliation(s)
- Julia K Lessing
- Duke University Hospital, Department of Pharmacy, Durham, NC.
| | - Shawn J Kram
- Duke University Hospital, Department of Pharmacy, Durham, NC
| | - Jerrold H Levy
- Duke University Hospital, Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham NC
| | - Loreta M Grecu
- Duke University Hospital, Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham NC
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, NC
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Donnelly S, Barnett CF, Bohula EA, Chaudhry SP, Chonde MD, Cooper HA, Daniels LB, Dodson MW, Gerber D, Goldfarb MJ, Guo J, Kontos MC, Liu S, Luk AC, Menon V, O'Brien CG, Papolos AI, Pisani BA, Potter BJ, Prasad R, Schnell G, Shah KS, Sridharan L, So DYF, Teuteberg JJ, Tymchak WJ, Zakaria S, Katz JN, Morrow DA, van Diepen S. Interhospital Variation in Admissions Managed With Critical Care Therapies or Invasive Hemodynamic Monitoring in Tertiary Cardiac Intensive Care Units: An Analysis From the Critical Care Cardiology Trials Network Registry. Circ Cardiovasc Qual Outcomes 2024; 17:e010092. [PMID: 38179787 DOI: 10.1161/circoutcomes.123.010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 11/14/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Wide interhospital variations exist in cardiovascular intensive care unit (CICU) admission practices and the use of critical care restricted therapies (CCRx), but little is known about the differences in patient acuity, CCRx utilization, and the associated outcomes within tertiary centers. METHODS The Critical Care Cardiology Trials Network is a multicenter registry of tertiary and academic CICUs in the United States and Canada that captured consecutive admissions in 2-month periods between 2017 and 2022. This analysis included 17 843 admissions across 34 sites and compared interhospital tertiles of CCRx (eg, mechanical ventilation, mechanical circulatory support, continuous renal replacement therapy) utilization and its adjusted association with in-hospital survival using logistic regression. The Pratt index was used to quantify patient-related and institutional factors associated with CCRx variability. RESULTS The median age of the study population was 66 (56-77) years and 37% were female. CCRx was provided to 62.2% (interhospital range of 21.3%-87.1%) of CICU patients. Admissions to CICUs with the highest tertile of CCRx utilization had a greater burden of comorbidities, had more diagnoses of ST-elevation myocardial infarction, cardiac arrest, or cardiogenic shock, and had higher Sequential Organ Failure Assessment scores. The unadjusted in-hospital mortality (median, 12.7%) was 9.6%, 11.1%, and 18.7% in low, intermediate, and high CCRx tertiles, respectively. No clinically meaningful differences in adjusted mortality were observed across tertiles when admissions were stratified by the provision of CCRx. Baseline patient-level variables and institutional differences accounted for 80% and 5.3% of the observed CCRx variability, respectively. CONCLUSIONS In a large registry of tertiary and academic CICUs, there was a >4-fold interhospital variation in the provision of CCRx that was primarily driven by differences in patient acuity compared with institutional differences. No differences were observed in adjusted mortality between low, intermediate, and high CCRx utilization sites.
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Affiliation(s)
- Sarah Donnelly
- Division of General Internal Medicine, Department of Medicine (S.D.), University of Alberta, Edmonton, Canada
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California, San Francisco (C.F.B., C.G.O.)
| | - 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, MA (E.A.B., J.G., D.A.M.)
| | - Sunit-Preet Chaudhry
- Division of Cardiology, Ascension St. Vincent Heart Center, Indianapolis, IN (S.-P.C.)
| | - Meshe D Chonde
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA (M.D.C.)
| | - Howard A Cooper
- Westchester Medical Center and New York Medical College, Valhalla (H.A.C.)
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla (L.B.D.)
| | - Mark W Dodson
- Department of Medicine, Intermountain Medical Center, Murray, UT (M.W.D.)
| | - Daniel Gerber
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, CA (D.G.)
| | - Michael J Goldfarb
- Division of Cardiology, Jewish General Hospital, Montreal, QC, Canada (M.J.G)
| | - Jianping Guo
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., J.G., D.A.M.)
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond (M.C.K.)
| | - Shuangbo Liu
- Max Rady College of Medicine, St. Boniface Hospital, Winnipeg, MB, Canada (S.L.)
| | - Adriana C Luk
- Peter Munk Cardiac Centre at Toronto General Hospital, Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada (A.C.L.)
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, OH (V.M.)
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California, San Francisco (C.F.B., C.G.O.)
| | - Alexander I Papolos
- Division of Cardiology, Department of Critical Care, MedStar Washington Hospital Center, DC (A.I.P.)
| | | | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal Research Center and Cardiovascular Center, QC, Canada (B.J.P.)
| | | | - Gregory Schnell
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (G.S.)
| | - Kevin S Shah
- University of Utah Health Sciences Center, Salt Lake City (K.S.S.)
| | | | - Derek Y F So
- University of Ottawa Heart Institute, ON, Canada (D.Y.F.S.)
| | | | - Wayne J Tymchak
- Department of Critical Care Medicine (W.J.T.), University of Alberta, Edmonton, Canada
- Division of Cardiology, Department of Medicine (W.J.T.), University of Alberta, Edmonton, Canada
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (S.Z.)
| | | | - 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, MA (E.A.B., J.G., D.A.M.)
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Pierce JB, Applefeld WN, Senman B, Loriaux DB, Lawler PR, Katz JN. Design and Execution of Clinical Trials in the Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:193-209. [PMID: 37973354 DOI: 10.1016/j.ccc.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Clinical practice in the contemporary cardiac intensive care unit (CICU) has evolved significantly over the last several decades. With more frequent multisystem organ failure, increasing use of advanced respiratory support, and the advent of new mechanical circulatory support platforms, clinicians in the CICU are increasingly managing patients with complex comorbid disease in addition to their high-acuity cardiovascular illnesses. Here, the authors discuss challenges associated with traditional trial design in the CICU setting and review novel clinical trial designs that may facilitate better evidence generation in the CICU.
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Affiliation(s)
- Jacob B Pierce
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Willard N Applefeld
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Balimkiz Senman
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Daniel B Loriaux
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Patrick R Lawler
- McGill University Health Centre, Montreal, Quebec, Canada; Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Jason N Katz
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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Mehra MR, Netuka I, Uriel N, Katz JN, Pagani FD, Jorde UP, Gustafsson F, Connors JM, Ivak P, Cowger J, Ransom J, Bansal A, Takeda K, Agarwal R, Byku M, Givertz MM, Bitar A, Hall S, Zimpfer D, Vega JD, Kanwar MK, Saeed O, Goldstein DJ, Cogswell R, Sheikh FH, Danter M, Pya Y, Phancao A, Henderson J, Crandall DL, Sundareswaran K, Soltesz E, Estep JD. Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure: The ARIES-HM3 Randomized Clinical Trial. JAMA 2023; 330:2171-2181. [PMID: 37950897 PMCID: PMC10640705 DOI: 10.1001/jama.2023.23204] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/24/2023] [Indexed: 11/13/2023]
Abstract
IMPORTANCE Left ventricular assist devices (LVADs) enhance quality and duration of life in advanced heart failure. The burden of nonsurgical bleeding events is a leading morbidity. Aspirin as an antiplatelet agent is mandated along with vitamin K antagonists (VKAs) with continuous-flow LVADs without conclusive evidence of efficacy and safety. OBJECTIVE To determine whether excluding aspirin as part of the antithrombotic regimen with a fully magnetically levitated LVAD is safe and decreases bleeding. DESIGN, SETTING, and PARTICIPANTS This international, randomized, double-blind, placebo-controlled study of aspirin (100 mg/d) vs placebo with VKA therapy in patients with advanced heart failure with an LVAD was conducted across 51 centers with expertise in treating patients with advanced heart failure across 9 countries. The randomized population included 628 patients with advanced heart failure implanted with a fully magnetically levitated LVAD (314 in the placebo group and 314 in the aspirin group), of whom 296 patients in the placebo group and 293 in the aspirin group were in the primary analysis population, which informed the primary end point analysis. The study enrolled patients from July 2020 to September 2022; median follow-up was 14 months. Intervention Patients were randomized in a 1:1 ratio to receive aspirin (100 mg/d) or placebo in addition to an antithrombotic regimen. MAIN OUTCOMES AND MEASURES The composite primary end point, assessed for noninferiority (-10% margin) of placebo, was survival free of a major nonsurgical (>14 days after implant) hemocompatibility-related adverse events (including stroke, pump thrombosis, major bleeding, or arterial peripheral thromboembolism) at 12 months. The principal secondary end point was nonsurgical bleeding events. RESULTS Of the 589 analyzed patients, 77% were men; one-third were Black and 61% were White. More patients were alive and free of hemocompatibility events at 12 months in the placebo group (74%) vs those taking aspirin (68%). Noninferiority of placebo was demonstrated (absolute between-group difference, 6.0% improvement in event-free survival with placebo [lower 1-sided 97.5% CI, -1.6%]; P < .001). Aspirin avoidance was associated with reduced nonsurgical bleeding events (relative risk, 0.66 [95% confidence limit, 0.51-0.85]; P = .002) with no increase in stroke or other thromboembolic events, a finding consistent among diverse subgroups of patient characteristics. CONCLUSIONS AND RELEVANCE In patients with advanced heart failure treated with a fully magnetically levitated LVAD, avoidance of aspirin as part of an antithrombotic regimen, which includes VKA, is not inferior to a regimen containing aspirin, does not increase thromboembolism risk, and is associated with a reduction in bleeding events. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04069156.
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Affiliation(s)
- Mandeep R. Mehra
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ivan Netuka
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Nir Uriel
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York
| | - Jason N. Katz
- Duke University Medical Center, Durham, North Carolina
| | | | - Ulrich P. Jorde
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York
| | - Finn Gustafsson
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jean M. Connors
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Peter Ivak
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - John Ransom
- Baptist Health Medical Center, Little Rock, Arkansas
| | | | - Koji Takeda
- Columbia University College of Physicians and Surgeons and New York Presbyterian Hospital, New York
| | - Richa Agarwal
- Duke University Medical Center, Durham, North Carolina
| | - Mirnela Byku
- University of North Carolina at Chapel Hill, Chapel Hill
| | - Michael M. Givertz
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | - Omar Saeed
- Montefiore Einstein Center for Heart and Vascular Care, New York, New York
| | | | | | | | | | - Yuriy Pya
- National Research Center for Cardiac Surgery, Kazakhstan
| | - Anita Phancao
- Miami Transplant Institute—Jackson Memorial, Miami, Florida
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20
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Tennyson CD, Bowers MT, Dimsdale AW, Dickinson SM, Sanford RM, McKenzie-Solis JD, Schimmer HD, Alviar CL, Sinha SS, Katz JN. Role of Advanced Practice Providers in the Cardiac Intensive Care Unit Team. J Am Coll Cardiol 2023; 82:2338-2342. [PMID: 38057076 DOI: 10.1016/j.jacc.2023.08.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/31/2023] [Accepted: 08/02/2023] [Indexed: 12/08/2023]
Affiliation(s)
- Carolina D Tennyson
- Duke University School of Nursing, Division of Cardiology, Duke Department of Medicine, Durham, North Carolina, USA.
| | - Margaret T Bowers
- Duke University School of Nursing, Division of Cardiology, Duke Department of Medicine, Durham, North Carolina, USA
| | - Allison W Dimsdale
- Duke University Health System, Advanced Practice Center, Division of Cardiology, Duke Department of Medicine, Durham, North Carolina, USA
| | | | | | | | - Hannah D Schimmer
- The Leon H. Charney Division of Cardiology, New York University Langone Medical Center & Bellevue Hospital Center, New York, New York, USA
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiology, New York University Langone Medical Center & Bellevue Hospital Center, New York, New York, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia, USA
| | - Jason N Katz
- Division of Cardiology, Duke Department of Medicine, Durham, North Carolina, USA
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21
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Yuzefpolskaya M, Fiedler AG, Katz JN, Houston BA. Is it time to stop living in a HeartMate II world? J Heart Lung Transplant 2023; 42:1621-1626. [PMID: 37536469 DOI: 10.1016/j.healun.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/30/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
Despite improving outcomes with modern pump technology, left ventricular assist device (LVAD) utilization for patients with end-stage heart failure (HF) has declined significantly in the preceding half-decade. Here, we examine this trend, noting an inherent contradiction in the declining utilization of an improving therapeutic option. We propose a series of provocative questions as a "call to action" for the field of advanced HF to consider both scientifically and clinically, focusing on our evaluation parameters for LVAD candidacy, our approach to dichotomous LVAD vs transplant decisions, and our current management paradigms. We conclude that modernization in these areas to match the advantages of modern pump technology is required to best serve patients with advanced HF.
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Affiliation(s)
- Melana Yuzefpolskaya
- Division of Cardiovascular Medicine, Columbia University Irving Medical Center, New York, New York
| | - Amy G Fiedler
- Department of Cardiac Surgery, University of California San Francisco, San Francisco, California
| | - Jason N Katz
- Division of Cardiology, Duke University, Durham, North Carolina
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
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22
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Berg DD, Kaur G, Bohula EA, Baird-Zars VM, Alviar CL, Barnett CF, Barsness GW, Burke JA, Chaudhry SP, Chonde M, Cooper HA, Daniels LB, Dodson MW, Gerber DA, Ghafghazi S, Gidwani UK, Goldfarb MJ, Guo J, Hillerson D, Kenigsberg BB, Kochar A, Kontos MC, Kwon Y, Lopes MS, Loriaux DB, Miller PE, O’Brien CG, Papolos AI, Patel SM, Pisani BA, Potter BJ, Prasad R, Roswell RO, Shah KS, Sinha SS, Smith TD, Solomon MA, Teuteberg JJ, Thompson AD, Zakaria S, Katz JN, van Diepen S, Morrow DA. Prognostic significance of haemodynamic parameters in patients with cardiogenic shock. Eur Heart J Acute Cardiovasc Care 2023; 12:651-660. [PMID: 37640029 PMCID: PMC10599641 DOI: 10.1093/ehjacc/zuad095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/17/2023] [Accepted: 08/06/2023] [Indexed: 08/31/2023]
Abstract
AIMS Invasive haemodynamic assessment with a pulmonary artery catheter is often used to guide the management of patients with cardiogenic shock (CS) and may provide important prognostic information. We aimed to assess prognostic associations and relationships to end-organ dysfunction of presenting haemodynamic parameters in CS. METHODS AND RESULTS The Critical Care Cardiology Trials Network is an investigator-initiated multicenter registry of cardiac intensive care units (CICUs) in North America coordinated by the TIMI Study Group. Patients with CS (2018-2022) who underwent invasive haemodynamic assessment within 24 h of CICU admission were included. Associations of haemodynamic parameters with in-hospital mortality were assessed using logistic regression, and associations with presenting serum lactate were assessed using least squares means regression. Sensitivity analyses were performed excluding patients on temporary mechanical circulatory support and adjusted for vasoactive-inotropic score. Among the 3603 admissions with CS, 1473 had haemodynamic data collected within 24 h of CICU admission. The median cardiac index was 1.9 (25th-75th percentile, 1.6-2.4) L/min/m2 and mean arterial pressure (MAP) was 74 (66-86) mmHg. Parameters associated with mortality included low MAP, low systolic blood pressure, low systemic vascular resistance, elevated right atrial pressure (RAP), elevated RAP/pulmonary capillary wedge pressure ratio, and low pulmonary artery pulsatility index. These associations were generally consistent when controlling for the intensity of background pharmacologic and mechanical haemodynamic support. These parameters were also associated with higher presenting serum lactate. CONCLUSION In a contemporary CS population, presenting haemodynamic parameters reflecting decreased systemic arterial tone and right ventricular dysfunction are associated with adverse outcomes and systemic hypoperfusion.
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Affiliation(s)
- David D Berg
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Gurleen Kaur
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Carlos L Alviar
- Leon H Charney Division of Cardiology, Bellevue Hospital Center, New York University School of Medicine, New York, NY, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - James A Burke
- Division of Cardiology, Lehigh Valley Heart Network, Allentown, PA, USA
| | | | - Meshe Chonde
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Howard A Cooper
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Mark W Dodson
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, USA
| | - Daniel A Gerber
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Shahab Ghafghazi
- Cardiovascular Medicine, University of Louisville, Louisville, KY, USA
| | - Umesh K Gidwani
- Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael J Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Jianping Guo
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Dustin Hillerson
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Benjamin B Kenigsberg
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ajar Kochar
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Michael C Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Younghoon Kwon
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Mathew S Lopes
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Daniel B Loriaux
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Connor G O’Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Siddharth M Patel
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Barbara A Pisani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Brian J Potter
- Cardiology Service, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM) Research Center and Cardiovascular Center, Montreal, QC, Canada
| | - Rajnish Prasad
- Division of Cardiology, Wellstar Health System, Marietta, GA, USA
| | - Robert O Roswell
- Division of Cardiology, Lenox Hill Hospital, Northwell Health, Zucker School of Medicine, New York, NY, USA
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA, USA
| | - Timothy D Smith
- Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH, USA
| | - 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, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea D Thompson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jason N Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
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Kadosh BS, Berg DD, Bohula EA, Park JG, Baird-Zars VM, Alviar C, Alzate J, Barnett CF, Barsness GW, Burke J, Chaudhry SP, Daniels LB, DeFilippis A, Delicce A, Fordyce CB, Ghafghazi S, Gidwani U, Goldfarb M, Katz JN, Keeley EC, Kenigsberg B, Kontos MC, Lawler PR, Leibner E, Menon V, Metkus TS, Miller PE, O'Brien CG, Papolos AI, Prasad R, Shah KS, Sinha SS, Snell RJ, So D, Solomon MA, Ternus BW, Teuteberg JJ, Toole J, van Diepen S, Morrow DA, Roswell RO. Pulmonary Artery Catheter Use and Mortality in the Cardiac Intensive Care Unit. JACC Heart Fail 2023; 11:903-914. [PMID: 37318422 PMCID: PMC10527413 DOI: 10.1016/j.jchf.2023.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND The appropriate use of pulmonary artery catheters (PACs) in critically ill cardiac patients remains debated. OBJECTIVES The authors aimed to characterize the current use of PACs in cardiac intensive care units (CICUs) with attention to patient-level and institutional factors influencing their application and explore the association with in-hospital mortality. METHODS The Critical Care Cardiology Trials Network is a multicenter network of CICUs in North America. Between 2017 and 2021, participating centers contributed annual 2-month snapshots of consecutive CICU admissions. Admission diagnoses, clinical and demographic data, use of PACs, and in-hospital mortality were captured. RESULTS Among 13,618 admissions at 34 sites, 3,827 were diagnosed with shock, with 2,583 of cardiogenic etiology. The use of mechanical circulatory support and heart failure were the patient-level factors most strongly associated with a greater likelihood of the use of a PAC (OR: 5.99 [95% CI: 5.15-6.98]; P < 0.001 and OR: 3.33 [95% CI: 2.91-3.81]; P < 0.001, respectively). The proportion of shock admissions with a PAC varied significantly by study center ranging from 8% to 73%. In analyses adjusted for factors associated with their placement, PAC use was associated with lower mortality in all shock patients admitted to a CICU (OR: 0.79 [95% CI: 0.66-0.96]; P = 0.017). CONCLUSIONS There is wide variation in the use of PACs that is not fully explained by patient level-factors and appears driven in part by institutional tendency. PAC use was associated with higher survival in cardiac patients with shock presenting to CICUs. Randomized trials are needed to guide the appropriate use of PACs in cardiac critical care.
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Affiliation(s)
- Bernard S Kadosh
- Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, New York University Langone Health, New York, New York, USA; Lenox Hospital, Northwell Health, New York, New York, 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, Massachusetts, USA
| | - 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, Massachusetts, USA
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, 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, Massachusetts, USA
| | - Carlos Alviar
- Department of Medicine at New York University Grossman School of Medicine, Bellevue Hospital, New York, New York, USA
| | - James Alzate
- Lenox Hospital, Northwell Health, New York, New York, USA
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - James Burke
- Lehigh Valley Heart Institute, Allentown, Pennsylvania, USA
| | | | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | | | | | - Christopher B Fordyce
- University of British Columbia, University of British Columbia Centre for Cardiovascular Innovation, Cardiovascular Health Program, University of British Columbia Centre for Health Evaluation and Outcomes Sciences, Vancouver, British Columbia, Canada
| | - Shahab Ghafghazi
- Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Umesh Gidwani
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ellen C Keeley
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Benjamin Kenigsberg
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Evan Leibner
- Department of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Thomas S Metkus
- Divisions of Cardiology and Cardiac Surgery, Departments of Medicine and Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Alexander I Papolos
- Departments of Cardiology and Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Rajnish Prasad
- Wellstar Cardiovascular Medicine, Marietta, Georgia, USA
| | - Kevin S Shah
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | | | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - 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
| | - Bradley W Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Jeffrey J Teuteberg
- Division of Cardiovascular Medicine, Stanford University Medical Center, Palo Alto, California, USA
| | - Joseph Toole
- Lenox Hospital, Northwell Health, New York, New York, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - 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, Massachusetts, USA
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Flores Rosario K, Federspiel JJ, Russell SD, Swartz JJ, Katz JN, Gray BA, Barnes S, Agarwal R. Pregnancy and Left Ventricular Assist Devices in the Post Roe v Wade Era. J Card Fail 2023; 29:959-962. [PMID: 37321700 PMCID: PMC10481998 DOI: 10.1016/j.cardfail.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Karen Flores Rosario
- Duke University Hospital, Department of Medicine, Division of Cardiology, Durham, North Carolina.
| | - Jerome J Federspiel
- Duke University Hospital, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Durham, North Carolina
| | - Stuart D Russell
- Duke University Hospital, Department of Medicine, Division of Cardiology, Durham, North Carolina
| | - Jonas J Swartz
- Duke University Hospital, Department of Obstetrics and Gynecology, Durham, North Carolina
| | - Jason N Katz
- Duke University Hospital, Department of Medicine, Division of Cardiology, Durham, North Carolina
| | - Beverly A Gray
- Duke University Hospital, Department of Obstetrics and Gynecology, Durham, North Carolina
| | - Stephanie Barnes
- Duke University Hospital, Division of Cardiology, Durham, North Carolina
| | - Richa Agarwal
- Duke University Hospital, Department of Medicine, Division of Cardiology, Durham, North Carolina
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Sinha SS, Katz JN, Morrow DA. Cultivating the Research Landscape for Critical Care Cardiology: The Case for Registry-Based Randomized Controlled Trials. Circulation 2023; 147:1637-1639. [PMID: 37253080 DOI: 10.1161/circulationaha.122.060802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S.)
| | - Jason N Katz
- Division of Cardiovascular Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC (J.N.K.)
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI (Thrombolysis in Myocardial Infarction) study group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.A.M.)
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Carnicelli AP, Agarwal R, Tedford RJ, Ramaiah V, Felker GM, Katz JN. Critical Care Enrichment During Advanced Heart Failure Training. J Am Coll Cardiol 2023; 81:1296-1299. [PMID: 36990549 DOI: 10.1016/j.jacc.2023.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 03/31/2023]
Affiliation(s)
- Anthony P Carnicelli
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.
| | - Richa Agarwal
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Vijay Ramaiah
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - G Michael Felker
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Jason N Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
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Metkus TS, Alviar CL, Baird-Zars VM, Barsness GW, Berg DD, Bohula EA, Burke JA, Fordyce CB, Guo J, Katz JN, Keeley EC, Menon V, Miller PE, O’Brien CG, Sinha SS, So D, Ternus BW, Vadhar S, van Diepen S, Morrow DA. Presentation and Outcomes of Patients With Preoperative Critical Illness Undergoing Cardiac Surgery. JACC Adv 2023; 2:100260. [PMID: 38357248 PMCID: PMC10865183 DOI: 10.1016/j.jacadv.2023.100260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
BACKGROUND Little is known about the prevalence and post-surgical outcomes associated with cardiac intensive care unit (CICU) therapeutics among CICU patients referred for cardiac surgery. OBJECTIVES The purpose of this study was to investigate the clinical characteristics and outcomes of CICU patients referred for cardiac surgery from the intensive care unit. METHODS We analyzed characteristics and outcomes of CICU admissions referred from the CICU for cardiac surgery during 2017 to 2020 across 29 centers. The primary outcome was in-hospital mortality. RESULTS Among 10,321 CICU admissions, 887 (8.6%) underwent cardiac surgery, including 406 (46%) coronary artery bypass graftings, 201 (23%) transplants or ventricular assist devices, 171 (19%) valve surgeries, and 109 (12%) other procedures. Common indications for CICU admission included shock (33.5%) and respiratory insufficiency (24.9%). Preoperative CICU therapies included vasoactive therapy in 52.2%, mechanical circulatory support in 35.9%, renal replacement in 8.2%, mechanical ventilation in 35.7%, and 17.5% with high-flow nasal cannula or noninvasive positive pressure ventilation. In-hospital mortality was 11.7% among all CICU admissions and 9.1% among patients treated with cardiac surgery. After multivariable adjustment, pre-op mechanical circulatory support and renal replacement therapy were associated with mortality, while respiratory support and vasoactive therapy were not. CONCLUSIONS Nearly 1 in 12 contemporary CICU patients receive cardiac surgery. Despite high preoperative disease severity, CICU admissions undergoing cardiac surgery had a comparable mortality rate to CICU patients overall; highlighting the ability of clinicians to select higher acuity patients with a reasonable perioperative risk.
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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, Maryland, USA
| | - Carlos L. Alviar
- Leon H. Charney Division of Cardiology, NYU Langone Medical Center, New York City, New York, 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, Massachusetts, USA
| | - Gregory W. Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, 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, Massachusetts, USA
| | - 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, Massachusetts, USA
| | - James A. Burke
- Lehigh Valley Heart and Vascular Institute, Allentown, Pennsylvania, USA
| | - Christopher B. Fordyce
- Division of Cardiology and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jianping Guo
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jason N. Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ellen C. Keeley
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - P. Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Connor G. O’Brien
- Division of Cardiology, Department of Medicine, University of California-San Francisco School of Medicine, San Francisco, California, USA
| | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Bradley W. Ternus
- Division of Cardiology, Department of Internal Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Sagar Vadhar
- Lehigh Valley Heart and Vascular Institute, Allentown, Pennsylvania, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - 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, Massachusetts, USA
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Price S, Kaski JC, Al-Lamee R, Boden WE, Huber K, Katz JN, Krychtiuk K. The year in cardiovascular medicine 2022: the top 10 papers in acute cardiac care and ischaemic heart disease. Eur Heart J 2023; 44:445-447. [PMID: 36587938 DOI: 10.1093/eurheartj/ehac811] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Susanna Price
- Royal Brompton & Harefield Hospitals, Guys' and St Thomas' NHS Foundation Trust and National Heart & Lung Institute, Imperial College, Sydney St, London SW3 6NP, UK
| | - Juan Carlos Kaski
- Molecular and Clinical Science Research Institute, St George's, University of London, London, UK
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, UK
| | - William E Boden
- VA Boston Healthcare System, Boston University School of Medicine and Harvard Medical School, Boston, MA, USA
| | - Kurt Huber
- Department of Cardiology and Intensive Care Medicine, Clinic Ottakring and Sigmund Freud University, Medical School, Vienna, Austria
| | - Jason N Katz
- Cardiac Intensive Care Unit, Duke University, Durham, NC, USA
| | - Konstantin Krychtiuk
- Duke Clinical Research Institute, Durham, NC, USA.,Department of Internal Medicine II - Division of Cardiology, Medical University of Vienna, Vienna, Austria
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Loriaux DB, McCartney S, Rampersad P, Bryner B, Katz JN. Preparing Cardiovascular Patients for the Operative Theatre. Eur Heart J Acute Cardiovasc Care 2023; 12:186-196. [PMID: 36746806 DOI: 10.1093/ehjacc/zuad005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023]
Affiliation(s)
| | | | | | - Benjamin Bryner
- Division of Cardiovascular Surgery, Northwestern, Chicago, IL
| | - Jason N Katz
- Division of Cardiology, Duke University, Durham, NC
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Matsumoto S, Kuno T, Mikami T, Takagi H, Ikeda T, Briasoulis A, Bortnick AE, Sims D, Katz JN, Jentzer J, Bangalore S, Alviar CL. Effect of cooling methods and target temperature on outcomes in comatose patients resuscitated from cardiac arrest: Systematic review and network meta-analysis of randomized trials. Am Heart J 2023; 256:73-84. [PMID: 36372248 DOI: 10.1016/j.ahj.2022.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/25/2022] [Accepted: 11/04/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Targeted temperature management (TTM) has been recommended after cardiac arrest (CA), however the specific temperature targets and cooling methods (intravascular cooling (IVC) versus surface cooling (SC)) remain uncertain. METHODS PUBMED and EMBASE were searched until October 8, 2022 for randomized clinical trials (RCTs) investigating the efficacy of TTM after CA. The randomized treatment arms were categorized into the following 6 groups: 31..C to 33..C IVC, 31..C to 33..C SC, 34..C to 36..C IVC, 34..C to 36..C SC, strict normothermia or fever prevention (Strict NT or FP), and standard of care without TTM (No-TTM). The primary outcome was neurological recovery. P-score was used to rank the treatments, where a larger value indicates better performance. RESULTS We identified 15 RCTs, involving 5,218 patients with CA. Compared to No-TTM as the reference, the other therapeutic options significantly improved neurological outcomes (vs No-TTM; 31..C to 33.. C IVC RR = 0.67, 95% CI 0.54 to 0.83; 31..C to 33..C SC RR = 0.73, 95% CI 0.61 to 0.87; 34..C to 36.. C IVC RR = 0.66, 95% CI 0.51 to 0.86; 34..C to 36..C SC: RR = 0.73, 0.59 to 0.90; Strict NT or FP: RR = 0.75, 95% CI 0.62 to 0.90). Overall, 31-33..C IVC had the highest probability to be the best therapeutic option to improve outcomes (the ranking P-score of 0.836). As a subgroup analysis, the ranking P-score showed that IVC might be a better cooling method compared to SC (IVC vs SC P-score: 0.960 vs 0.670). CONCLUSIONS Hypothermia (31..C to 36..C IVC and SC) and active normothermia (Strict-NT and Strict-FP) were associated with better neurological outcomes compared to No-TTM, with IVC having a greater probability of being the better cooling method than SC.
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Affiliation(s)
- Shingo Matsumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Toshiki Kuno
- Department of Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine Bronx, NY.
| | | | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Takanori Ikeda
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | | | - Anna E Bortnick
- Department of Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine Bronx, NY
| | - Daniel Sims
- Department of Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine Bronx, NY
| | - Jason N Katz
- Division of Cardiovascular Medicine, Duke University, Durham, NC
| | - Jacob Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sripal Bangalore
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, New York, NY
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Grossman School of Medicine, New York, NY
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Bensen GP, Rogers AC, Leifer VP, Edwards RR, Neogi T, Kostic AM, Paltiel AD, Collins JE, Hunter DJ, Katz JN, Losina E. Does gabapentin provide benefit for patients with knee OA? A benefit-harm and cost-effectiveness analysis. Osteoarthritis Cartilage 2023; 31:279-290. [PMID: 36414225 PMCID: PMC9892279 DOI: 10.1016/j.joca.2022.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 05/25/2022] [Accepted: 07/08/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Gabapentin can treat neuropathic pain syndromes and has increasingly been prescribed to treat nociplastic pain. Some patients with knee osteoarthritis (OA) suffer from both nociceptive and nociplastic pain. We examined the cost-effectiveness of adding gabapentin to knee OA care. METHOD We used the Osteoarthritis Policy Model, a validated Monte Carlo simulation of knee OA, to examine the value of gabapentin in treating knee OA by comparing three strategies: 1) usual care, gabapentin sparing (UC-GS); 2) targeted gabapentin (TG), which provides gabapentin plus usual care for those who screen positive for nociplastic pain on the modified PainDETECT questionnaire (mPD-Q) and usual care only for those who screen negative; and 3) universal gabapentin plus usual care (UG). Outcomes included cumulative quality-adjusted life years (QALYs), lifetime direct medical costs, and incremental cost-effectiveness ratios (ICERs), discounted at 3% annually. We derived model inputs from published literature and national databases and varied key input parameters in sensitivity analyses. RESULTS UC-GS dominated both gabapentin-containing strategies, as it led to lower costs and more QALYs. TG resulted in a cost increase of $689 and a cumulative QALY reduction of 0.012 QALYs. UG resulted in a further $1,868 cost increase and 0.036 QALY decrease. The results were robust to plausible changes in input parameters. The lowest TG strategy ICER of $53,000/QALY was reported when mPD-Q specificity was increased to 100% and AE rate was reduced to 0%. CONCLUSION Incorporating gabapentin into care for patients with knee OA does not appear to offer good value.
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Affiliation(s)
- G P Bensen
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - A C Rogers
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - V P Leifer
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - R R Edwards
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA, USA.
| | - T Neogi
- Boston University School of Medicine, Boston, MA, USA.
| | - A M Kostic
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - A D Paltiel
- Public Health Modeling Unit, Yale School of Public Health, New Haven, CT, USA.
| | - J E Collins
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - D J Hunter
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney and Rheumatology Department, Royal North Shore Hospital, Sydney, Australia.
| | - J N Katz
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - E Losina
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Policy and Innovation eValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Rheumatology, Inflammation and Immunity, Brigham and Women's Hospital, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA.
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Carnicelli AP, Keane R, Brown KM, Loriaux DB, Kendsersky P, Alviar CL, Arps K, Berg DD, Bohula EA, Burke JA, Dixson JA, Gerber DA, Goldfarb M, Granger CB, Guo J, Harrison RW, Kontos M, Lawler PR, Miller PE, Nativi-Nicolau J, Newby LK, Racharla L, Roswell RO, Shah KS, Sinha SS, Solomon MA, Teuteberg J, Wong G, van Diepen S, Katz JN, Morrow DA. Characteristics, therapies, and outcomes of In-Hospital vs Out-of-Hospital cardiac arrest in patients presenting to cardiac intensive care units: From the critical care Cardiology trials network (CCCTN). Resuscitation 2023; 183:109664. [PMID: 36521683 PMCID: PMC9899313 DOI: 10.1016/j.resuscitation.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/19/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cardiac arrest (CA) is a common reason for admission to the cardiac intensive care unit (CICU), though the relative burden of morbidity, mortality, and resource use between admissions with in-hospital (IH) and out-of-hospital (OH) CA is unknown. We compared characteristics, care patterns, and outcomes of admissions to contemporary CICUs after IHCA or OHCA. METHODS The Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs in the US and Canada. Participating centers contributed data from consecutive admissions during 2-month annual snapshots from 2017 to 2021. We analyzed characteristics and outcomes of admissions by IHCA vs OHCA. RESULTS We analyzed 2,075 admissions across 29 centers (50.3% IHCA, 49.7% OHCA). Admissions with IHCA were older (median 66 vs 62 years), more commonly had coronary disease (38.3% vs 29.7%), atrial fibrillation (26.7% vs 15.6%), and heart failure (36.3% vs 22.1%), and were less commonly comatose on CICU arrival (34.2% vs 71.7%), p < 0.001 for all. IHCA admissions had lower lactate (median 4.3 vs 5.9) but greater utilization of invasive hemodynamics (34.3% vs 23.6%), mechanical circulatory support (28.4% vs 16.8%), and renal replacement therapy (15.5% vs 9.4%); p < 0.001 for all. Comatose IHCA patients underwent targeted temperature management less frequently than OHCA patients (63.3% vs 84.9%, p < 0.001). IHCA admissions had lower unadjusted CICU (30.8% vs 39.0%, p < 0.001) and in-hospital mortality (36.1% vs 44.1%, p < 0.001). CONCLUSION Despite a greater burden of comorbidities, CICU admissions after IHCA have lower lactate, greater invasive therapy utilization, and lower crude mortality than admissions after OHCA.
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Affiliation(s)
- Anthony P Carnicelli
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Ryan Keane
- Division of Cardiology, Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kelly M Brown
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Daniel B Loriaux
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Payton Kendsersky
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Carlos L Alviar
- Leon H Charney Division of Cardiology, Bellevue Hospital Center, New York University School of Medicine, New York, NY, USA
| | - Kelly Arps
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Jeffrey A Dixson
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - Daniel A Gerber
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Jianping Guo
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Michael Kontos
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jose Nativi-Nicolau
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - L Kristin Newby
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | | | - Robert O Roswell
- Lennox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Kevin S Shah
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - 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, USA
| | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Graham Wong
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Alberta, Canada
| | - Jason N Katz
- Duke University Hospital, Division of Cardiology, Durham, NC, USA
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Chouairi F, Miller PE, Loriaux DB, Katz JN, Sen S, Ahmad T, Fudim M. Trends and Outcomes in Cardiac Arrest Among Heart Failure Admissions. Am J Cardiol 2023; 194:93-101. [PMID: 36889986 DOI: 10.1016/j.amjcard.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/06/2022] [Accepted: 01/07/2023] [Indexed: 03/08/2023]
Abstract
There is limited large, national data investigating the prevalence, characteristics, and outcomes of cardiac arrest (CA) in patients hospitalized for heart failure (HF). The goal of this study was to examine the characteristics, trends, and outcomes of HF hospitalizations complicated by in-hospital CA. We used the National Inpatient Sample to identify all primary HF admissions from 2016 to 2019. Cohorts were built based on the presence of a codiagnosis of CA. Diagnoses were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. Associations with CA were then analyzed using multivariate logistic regression. We identified a total of 4,905,564 HF admissions, 56,170 (1.1%) of which had CA. Hospitalizations complicated by CA were significantly more likely to be male, to have coronary artery disease, renal disease, and less likely to be White (p <0.001, all). Age <65 (odds ratio [OR] 1.18, p <0.001), renal disease (OR 2.41, p <0.001), and coronary artery disease (OR 1.26, p <0.001) had higher odds of CA while female gender (OR 0.84, confidence interval [CI] 0.83 to 0.86, p <0.001) or HFpEF (OR 0.49, CI 0.48 to 0.50, p <0.001) had lower odds of CA. Patients with CA had higher inpatient mortality (CA 54.2% vs no CA 2.1%, p <0.001), which persisted after multivariate adjustment (OR 64.8, CI 63.5 to 66.0, p <0.001). CA occurs in >1 in 1,000 HF hospitalizations and remains a prominent and serious event associated with a high mortality. Further research is needed to examine long-term outcomes and mechanical circulatory support utilization with more granularity in HF patients with in-hospital CA.
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Affiliation(s)
- Fouad Chouairi
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Daniel B Loriaux
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jason N Katz
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Sounok Sen
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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Patel SM, Berg DD, Bohula EA, Baird-Zars VM, Barnett CF, Barsness GW, Chaudhry SP, Daniels LB, van Diepen S, Ghafghazi S, Goldfarb MJ, Jentzer JC, Katz JN, Kenigsberg BB, Lawler PR, Miller PE, Papolos AI, Park JG, Potter BJ, Prasad R, Singam NSV, Sinha SS, Solomon MA, Teuteberg JJ, Morrow DA. Clinician and Algorithmic Application of the 2019 and 2022 Society of Cardiovascular Angiography and Intervention Shock Stages in the Critical Care Cardiology Trials Network Registry. Circ Heart Fail 2023; 16:e009714. [PMID: 36458542 PMCID: PMC9851990 DOI: 10.1161/circheartfailure.122.009714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 09/20/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Algorithmic application of the 2019 Society of Cardiovascular Angiography and Intervention (SCAI) shock stages effectively stratifies mortality risk for patients with cardiogenic shock. However, clinician assessment of SCAI staging may differ. Moreover, the implications of the 2022 SCAI criteria update remain incompletely defined. METHODS The Critical Care Cardiology Trials Network is a multicenter registry of cardiac intensive care units (CICUs). Between 2019 and 2021, participating centers (n=32) contributed at least a 2-month snapshot of consecutive medical CICU admissions. In-hospital mortality was assessed across 3 separate staging methods: clinician assessment, Critical Care Cardiology Trials Network algorithmic application of the 2019 SCAI criteria, and a revision of the Critical Care Cardiology Trials Network application using the 2022 SCAI criteria. RESULTS Of 9612 admissions, 1340 (13.9%) presented with cardiogenic shock with in-hospital mortality of 35.2%. Both clinician and algorithm-based staging using the 2019 SCAI criteria identified a stepwise gradient of mortality risk (stage C-E: 19.0% to 83.7% and 14.6% to 52.2%, respectively; Ptrend<0.001 for each). Clinician assignment of SCAI stages identified higher risk patients compared with algorithm-based assignment (stage D: 49.9% versus 29.3%; stage E: 83.7% versus 52.2%). Algorithmic application of the 2022 SCAI criteria, with incorporation of the vasoactive-inotropic score, more closely approximated clinician staging (mortality for stage C-E: 21.9% to 70.5%; Ptrend<0.001). CONCLUSIONS Both clinician and algorithm-based application of the 2019 SCAI stages identify a stepwise gradient of mortality risk, although clinician-staging may better allocate higher risk patients into advanced SCAI stages. Updated algorithmic staging using the 2022 SCAI criteria and vasoactive-inotropic score further refines risk stratification.
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Affiliation(s)
- Siddharth M. Patel
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David D. Berg
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - 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, USA
| | - 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, USA
| | - Christopher F. Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Gregory W. Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Lori B. Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Shahab Ghafghazi
- Cardiovascular Medicine, University of Louisville, Louisville, Kentucky, USA
| | | | - Jacob C. Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason N. Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Benjamin B. Kenigsberg
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Patrick R. Lawler
- Peter Munk Cardiac Centre at Toronto General Hospital, Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - P. Elliot Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alexander I. Papolos
- Departments of Cardiology and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - 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, USA
| | - Brian J. Potter
- Centre Hospitalier de l’Université de Montréal (CHUM) Research Center and Cardiovascular Center, Montreal, QC, Canada
| | | | - N. Sarma V. Singam
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia, USA
| | - 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
| | - Jeffrey J. Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - 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, USA
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Cox CE, Gu J, Ashana DC, Pratt EH, Haines K, Ma J, Olsen MK, Parish A, Casarett D, Al-Hegelan MS, Naglee C, Katz JN, O'Keefe YA, Harrison RW, Riley IL, Bermejo S, Dempsey K, Johnson KS, Docherty SL. Trajectories of Palliative Care Needs in the ICU and Long-Term Psychological Distress Symptoms. Crit Care Med 2023; 51:13-24. [PMID: 36326263 PMCID: PMC10191149 DOI: 10.1097/ccm.0000000000005701] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES While palliative care needs are assumed to improve during ICU care, few empiric data exist on need trajectories or their impact on long-term outcomes. We aimed to describe trajectories of palliative care needs during ICU care and to determine if changes in needs over 1 week was associated with similar changes in psychological distress symptoms at 3 months. DESIGN Prospective cohort study. SETTING Six adult medical and surgical ICUs. PARTICIPANTS Patients receiving mechanical ventilation for greater than or equal to 2 days and their family members. MEASUREMENTS AND MAIN RESULTS The primary outcome was the 13-item Needs at the End-of-Life Screening Tool (NEST; total score range 0-130) completed by family members at baseline, 3, and 7 days. The Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Post-Traumatic Stress Scale (PTSS) were completed at baseline and 3 months. General linear models were used to estimate differences in distress symptoms by change in need (NEST improvement ≥ 10 points or not). One-hundred fifty-nine family members participated (median age, 54.0 yr [interquartile range (IQR), 44.0-63.0 yr], 125 [78.6%] female, 54 [34.0%] African American). At 7 days, 53 (33%) a serious level of overall need and 35 (22%) ranked greater than or equal to 1 individual need at the highest severity level. NEST scores improved greater than or equal to 10 points in only 47 (30%). Median NEST scores were 22 (IQR, 12-40) at baseline and 19 (IQR, 9-37) at 7 days (change, -2.0; IQR, -11.0 to 5.0; p = 0.12). There were no differences in PHQ-9, GAD-7, or PTSS change scores by change in NEST score (all p > 0.15). CONCLUSIONS Serious palliative care needs were common and persistent among families during ICU care. Improvement in needs was not associated with less psychological distress at 3 months. Serious needs may be commonly underrecognized in current practice.
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Affiliation(s)
- Christopher E Cox
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Jessie Gu
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Deepshikha Charan Ashana
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Elias H Pratt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Krista Haines
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, NC
| | - Jessica Ma
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC
- Geriatric Research, Education, and Clinical Center, Durham VA Healthcare System, Durham, NC
| | - Maren K Olsen
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - David Casarett
- Department of Medicine, Section of Palliative Care and Hospice Medicine, Duke University, Durham, NC
| | - Mashael S Al-Hegelan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, NC
- Department of Neurology, Division of Neurocritical Care, Duke University, Durham, NC
| | - Jason N Katz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Yasmin Ali O'Keefe
- Department of Neurology, Division of Neurocritical Care, Duke University, Durham, NC
| | - Robert W Harrison
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Isaretta L Riley
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Santos Bermejo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Katelyn Dempsey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Kimberly S Johnson
- Geriatric Research, Education, and Clinical Center, Durham VA Healthcare System, Durham, NC
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, NC
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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: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Vallabhajosyula S, Verghese D, Henry TD, Katz JN, Nicholson WJ, Jaber WA, Jentzer JC. Contemporary Management of Concomitant Cardiac Arrest and Cardiogenic Shock Complicating Myocardial Infarction. Mayo Clin Proc 2022; 97:2333-2354. [PMID: 36464466 DOI: 10.1016/j.mayocp.2022.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 06/08/2022] [Accepted: 06/24/2022] [Indexed: 12/03/2022]
Abstract
Cardiogenic shock (CS) and cardiac arrest (CA) are the most life-threatening complications of acute myocardial infarction. Although there is a significant overlap in the pathophysiology with approximately half the patients with CS experiencing a CA and approximately two-thirds of patients with CA developing CS, comprehensive guideline recommendations for management of CA + CS are lacking. This paper summarizes the current evidence on the incidence, pathophysiology, and short- and long-term outcomes of patients with acute myocardial infarction complicated by concomitant CA + CS. We discuss the hemodynamic factors and unique challenges that need to be accounted for while developing treatment strategies for these patients. A summary of expert-based step-by-step recommendations to the approach and treatment of these patients, both in the field before admission and in-hospital management, are presented.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Dhiran Verghese
- Section of Advanced Cardiac Imaging, Division of Cardiovascular Medicine, Department of Medicine, Harbor UCLA Medical Center, Torrance, CA, USA; Department of Cardiovascular Medicine, NCH Heart Institute, Naples, FL, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital Health Network, Cincinnati, OH, USA
| | - Jason N Katz
- Divisions of Cardiovascular Diseases and Pulmonary and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - William J Nicholson
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Wissam A Jaber
- Section of Interventional Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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38
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Bohula EA, Berg DD, Lopes MS, Connors JM, Babar I, Barnett CF, Chaudhry SP, Chopra A, Ginete W, Ieong MH, Katz JN, Kim EY, Kuder JF, Mazza E, McLean D, Mosier JM, Moskowitz A, Murphy SA, O’Donoghue ML, Park JG, Prasad R, Ruff CT, Shahrour MN, Sinha SS, Wiviott SD, Van Diepen S, Zainea M, Baird-Zars V, Sabatine MS, Morrow DA. Anticoagulation and Antiplatelet Therapy for Prevention of Venous and Arterial Thrombotic Events in Critically Ill Patients With COVID-19: COVID-PACT. Circulation 2022; 146:1344-1356. [PMID: 36036760 PMCID: PMC9624238 DOI: 10.1161/circulationaha.122.061533] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The efficacy and safety of prophylactic full-dose anticoagulation and antiplatelet therapy in critically ill COVID-19 patients remain uncertain. METHODS COVID-PACT (Prevention of Arteriovenous Thrombotic Events in Critically-ill COVID-19 Patients Trial) was a multicenter, 2×2 factorial, open-label, randomized-controlled trial with blinded end point adjudication in intensive care unit-level patients with COVID-19. Patients were randomly assigned to a strategy of full-dose anticoagulation or standard-dose prophylactic anticoagulation. Absent an indication for antiplatelet therapy, patients were additionally randomly assigned to either clopidogrel or no antiplatelet therapy. The primary efficacy outcome was the hierarchical composite of death attributable to venous or arterial thrombosis, pulmonary embolism, clinically evident deep venous thrombosis, type 1 myocardial infarction, ischemic stroke, systemic embolic event or acute limb ischemia, or clinically silent deep venous thrombosis, through hospital discharge or 28 days. The primary efficacy analyses included an unmatched win ratio and time-to-first event analysis while patients were on treatment. The primary safety outcome was fatal or life-threatening bleeding. The secondary safety outcome was moderate to severe bleeding. Recruitment was stopped early in March 2022 (≈50% planned recruitment) because of waning intensive care unit-level COVID-19 rates. RESULTS At 34 centers in the United States, 390 patients were randomly assigned between anticoagulation strategies and 292 between antiplatelet strategies (382 and 290 in the on-treatment analyses). At randomization, 99% of patients required advanced respiratory therapy, including 15% requiring invasive mechanical ventilation; 40% required invasive ventilation during hospitalization. Comparing anticoagulation strategies, a greater proportion of wins occurred with full-dose anticoagulation (12.3%) versus standard-dose prophylactic anticoagulation (6.4%; win ratio, 1.95 [95% CI, 1.08-3.55]; P=0.028). Results were consistent in time-to-event analysis for the primary efficacy end point (full-dose versus standard-dose incidence 19/191 [9.9%] versus 29/191 [15.2%]; hazard ratio, 0.56 [95% CI, 0.32-0.99]; P=0.046). The primary safety end point occurred in 4 (2.1%) on full dose and in 1 (0.5%) on standard dose (P=0.19); the secondary safety end point occurred in 15 (7.9%) versus 1 (0.5%; P=0.002). There was no difference in all-cause mortality (hazard ratio, 0.91 [95% CI, 0.56-1.48]; P=0.70). There were no differences in the primary efficacy or safety end points with clopidogrel versus no antiplatelet therapy. CONCLUSIONS In critically ill patients with COVID-19, full-dose anticoagulation, but not clopidogrel, reduced thrombotic complications with an increase in bleeding, driven primarily by transfusions in hemodynamically stable patients, and no apparent excess in mortality. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04409834.
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Affiliation(s)
- Erin A. Bohula
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - David D. Berg
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Mathew S. Lopes
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jean M. Connors
- Hematology Division (J.M.C.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Ijlal Babar
- Singing River Health System, Ocean Springs, MS (I.B.)
| | | | | | - Amit Chopra
- Division of Pulmonary and Critical Care Medicine, Albany Medical Center, NY (A.C.)
| | - Wilson Ginete
- Essentia Health St. Mary’s Medical Center, Duluth, MN (W.G.)
| | - Michael H. Ieong
- The Pulmonary Center, Boston University School of Medicine, MA (M.H.I.)
| | - Jason N. Katz
- Division of Cardiovascular Medicine, Duke University School of Medicine, Durham, NC (J.N.K.)
| | - Edy Y. Kim
- Pulmonary and Critical Care Medicine Division (E.Y.K.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Julia F. Kuder
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Dalton McLean
- Moses H. Cone Memorial Hospital, Greensboro, NC (D.M.)
| | - Jarrod M. Mosier
- Department of Emergency Medicine and Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, The University of Arizona College of Medicine, Tucson (J.M.M.)
| | - Ari Moskowitz
- Beth Israel Deaconess Medical Center, Boston, MA (A.M.)
| | - Sabina A. Murphy
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Michelle L. O’Donoghue
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Christian T. Ruff
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | | | - Shashank S. Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA (S.S.S.)
| | - Stephen D. Wiviott
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Sean Van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.V.D.)
| | | | - Vivian Baird-Zars
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Marc S. Sabatine
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division (E.A.B., D.D.B., M.S.L., J.F.K., S.A.M., M.L.O., J.-G.P., C.T.R., S.D.W., V.B.-Z., M.S.S., D.A.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
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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. Eur Heart J Qual Care Clin Outcomes 2022; 8:703-708. [PMID: 36029517 PMCID: PMC9603535 DOI: 10.1093/ehjqcco/qcac055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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40
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Cox CE, Olsen MK, Parish A, Gu J, Ashana DC, Pratt EH, Haines K, Ma J, Casarett DJ, Al-Hegelan MS, Naglee C, Katz JN, O'Keefe YA, Harrison RW, Riley IL, Bermejo S, Dempsey K, Wolery S, Jaggers J, Johnson KS, Docherty SL. Palliative care phenotypes among critically ill patients and family members: intensive care unit prospective cohort study. BMJ Support Palliat Care 2022:bmjspcare-2022-003622. [PMID: 36167642 PMCID: PMC10085460 DOI: 10.1136/spcare-2022-003622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 09/16/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Because the heterogeneity of patients in intensive care units (ICUs) and family members represents a challenge to palliative care delivery, we aimed to determine if distinct phenotypes of palliative care needs exist. METHODS Prospective cohort study conducted among family members of adult patients undergoing mechanical ventilation in six medical and surgical ICUs. The primary outcome was palliative care need measured by the Needs at the End-of-Life Screening Tool (NEST, range from 0 (no need) to 130 (highest need)) completed 3 days after ICU admission. We also assessed quality of communication, clinician-family relationship and patient centredness of care. Latent class analysis of the NEST's 13 items was used to identify groups with similar patterns of serious palliative care needs. RESULTS Among 257 family members, latent class analysis yielded a four-class model including complex communication needs (n=26, 10%; median NEST score 68.0), family spiritual and cultural needs (n=21, 8%; 40.0) and patient and family stress needs (n=43, 31%; 31.0), as well as a fourth group with fewer serious needs (n=167, 65%; 14.0). Interclass differences existed in quality of communication (median range 4.0-10.0, p<0.001), favourable clinician-family relationship (range 34.6%-98.2%, p<0.001) and both the patient centredness of care Eliciting Concerns (median range 4.0-5.0, p<0.001) and Decision-Making (median range 2.3-4.5, p<0.001) scales. CONCLUSIONS Four novel phenotypes of palliative care need were identified among ICU family members with distinct differences in the severity of needs and perceived quality of the clinician-family interaction. Knowledge of need class may help to inform the development of more person-centred models of ICU-based palliative care.
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Affiliation(s)
- Christopher E Cox
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Maren K Olsen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Jessie Gu
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Deepshikha Charan Ashana
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Elias H Pratt
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Krista Haines
- Department of Surgery, Division of Trauma and Critical Care and Acute Care Surgery, Duke University, Durham, NC, USA
| | - Jessica Ma
- Section of Palliative Care and Hospice Medicine, Duke University, Durham, NC, USA
| | - David J Casarett
- Section of Palliative Care and Hospice Medicine, Duke University, Durham, NC, USA
| | - Mashael S Al-Hegelan
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Colleen Naglee
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
- Department of Neurology, Division of Neurocritical Care, Durham, North Carolina, USA
| | - Jason N Katz
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, USA
| | - Yasmin Ali O'Keefe
- Department of Neurology, Division of Neurocritical Care, Durham, North Carolina, USA
| | - Robert W Harrison
- Department of Medicine, Division of Cardiology, Duke University, Durham, NC, USA
| | - Isaretta L Riley
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | - Santos Bermejo
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Katelyn Dempsey
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Shayna Wolery
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Jennie Jaggers
- Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina, USA
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC, USA
| | - Kimberly S Johnson
- Division of Geriatrics, Center for Study of Aging and Human Development, Duke University, Durham, NC, USA
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Geller BJ, Sinha SS, Kapur NK, Bakitas M, Balsam LB, Chikwe J, Klein DG, Kochar A, Masri SC, Sims DB, Wong GC, Katz JN, van Diepen S. Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e50-e68. [PMID: 35862152 DOI: 10.1161/cir.0000000000001076] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of temporary mechanical circulatory support in cardiogenic shock has increased dramatically despite a lack of randomized controlled trials or evidence guiding clinical decision-making. Recommendations from professional societies on temporary mechanical circulatory support escalation and de-escalation are limited. This scientific statement provides pragmatic suggestions on temporary mechanical circulatory support device selection, escalation, and weaning strategies in patients with common cardiogenic shock causes such as acute decompensated heart failure and acute myocardial infarction. The goal of this scientific statement is to serve as a resource for clinicians making temporary mechanical circulatory support management decisions and to propose standardized approaches for their use until more robust randomized clinical data are available.
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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 Adv 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] [What about the content of this article? (0)] [Affiliation(s)] [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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43
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Fagundes A, Berg DD, Park JG, Baird-Zars VM, Newby LK, Barsness GW, Miller PE, van Diepen S, Katz JN, Phreaner N, Roswell RO, Menon V, Daniels LB, Morrow DA, Bohula EA. Patients With Acute Coronary Syndromes Admitted to Contemporary Cardiac Intensive Care Units: Insights From the CCCTN Registry. Circ Cardiovasc Qual Outcomes 2022; 15:e008652. [DOI: 10.1161/circoutcomes.121.008652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
With the improvement in outcomes for acute coronary syndrome (ACS), the practice of routine admission to cardiac intensive care units (CICUs) is evolving. We aimed to describe the epidemiology of patients with ACS admitted to contemporary CICUs.
METHODS:
Using the CCCTN (Critical Care Cardiology Trials Network) Registry for consecutive medical CICU admissions across 26 advanced CICUs in North America between 2017 and 2020, we identified patients with a primary diagnosis of ACS at CICU admission and compared patient characteristics, resource utilization, and outcomes to patients admitted with a non-ACS diagnosis and across sub-populations of patients with ACS, including by indication for CICU admission.
RESULTS:
Of 10 118 CICU admissions, 29.4% (n=2978) were for a primary diagnosis of ACS, with significant interhospital variability (range, 13.4%–56.6%). Compared with patients admitted with a diagnosis other than ACS, patients with ACS had fewer comorbidities, lower acute severity of illness with less utilization of advanced CICU therapies (41.3% versus 66.1%,
P
<0.0001), and lower CICU mortality (5.4% versus 9.9%,
P
<0.0001). Monitoring alone, without another CICU indication at the time of admission, was the most frequent admission indication in patients with ACS (53.8%); less common indications in patients with ACS included respiratory insufficiency, shock, or the need for vasoactive therapy. Of patients with ACS admitted for monitoring alone, 94.8% did not subsequently require advanced intensive care unit therapies and had a low CICU length of stay (1.5 days [0.9–2.4] versus 2.6 [1.4–5.1],
P
<0.0001) and CICU mortality (0.6% versus 11.0%,
P
<0.0001), compared with patients with ACS with an admission indication beyond monitoring.
CONCLUSIONS:
In a registry of tertiary care CICUs, ACS represent ≈1/3 of all admissions with significant variability across hospitals. More than half of the ACS admissions to the CICU were for routine monitoring alone, with a low rate of complications and mortality. This observation highlights an opportunity for prospective studies to refine triage strategies for lower risk patients with ACS.
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Affiliation(s)
- Antonio Fagundes
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - David D. Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - Vivian M. Baird-Zars
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - L. Kristin Newby
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (L.K.N., J.N.K)
| | | | - P. Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (P.E.M.)
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.v.D.)
| | - Jason N. Katz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (L.K.N., J.N.K)
| | - Nicholas Phreaner
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (N.P., L.B.D.)
| | | | | | - Lori B. Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (N.P., L.B.D.)
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - Erin A. Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
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44
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Kim JM, Godfrey S, O'Neill D, Sinha SS, Kochar A, Kapur NK, Katz JN, Warraich HJ. Integrating palliative care into the modern cardiac intensive care unit: a review. Eur Heart J Acute Cardiovasc Care 2022; 11:442-449. [PMID: 35363258 DOI: 10.1093/ehjacc/zuac034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 06/14/2023]
Abstract
The modern cardiac intensive care unit (CICU) specializes in the care of a broad range of critically ill patients with both cardiac and non-cardiac serious illnesses. Despite advances, most conditions that necessitate CICU admission such as cardiogenic shock, continue to have a high burden of morbidity and mortality. The CICU often serves as the final destination for patients with end-stage disease, with one study reporting that one in five patients in the USA die in an intensive care unit (ICU) or shortly after an ICU admission. Palliative care is a broad subspecialty of medicine with an interdisciplinary approach that focuses on optimizing patient and family quality of life (QoL), decision-making, and experience. Palliative care has been shown to improve the QoL and symptom burden in patients at various stages of illness, however, the integration of palliative care in the CICU has not been well-studied. In this review, we outline the fundamental principles of high-quality palliative care in the ICU, focused on timeliness, goal-concordant decision-making, and family-centred care. We differentiate between primary palliative care, which is delivered by the primary CICU team, and secondary palliative care, which is provided by the consulting palliative care team, and delineate their responsibilities and domains. We propose clinical triggers that might spur serious illness communication and reappraisal of patient preferences. More research is needed to test different models that integrate palliative care in the modern CICU.
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Affiliation(s)
- Joseph M Kim
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Godfrey
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Deirdre O'Neill
- Department of Medicine and Mazankowski Heart Institute, Division of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | | | - Ajar Kochar
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Navin K Kapur
- Department of Medicine, Division of Cardiology, The Cardiovascular Center, Tufts Medical Center, Boston, MA, USA
| | - Jason N Katz
- Department of Medicine, Division of Cardiovascular Medicine, Duke University Medical Center, Durham, NC, USA
| | - Haider J Warraich
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, MA, USA
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45
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van Diepen S, Katz JN. A Call to Move from Point-in-Time towards Comprehensive Dynamic Risk Prediction in Critically Ill Patients with Heart Failure. J Card Fail 2022; 28:1100-1103. [PMID: 35561895 DOI: 10.1016/j.cardfail.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada.
| | - Jason N Katz
- Divison of Cardiology, Duke University School of Medicine, Durham, NC, USA
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46
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Padkins M, Fanaroff A, Bennett C, Wiley B, Barsness G, van Diepen S, Katz JN, Jentzer JC. Epidemiology and Outcomes of Patients Readmitted to the Intensive Care Unit After Cardiac Intensive Care Unit Admission. Am J Cardiol 2022; 170:138-146. [PMID: 35393081 DOI: 10.1016/j.amjcard.2022.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/06/2022] [Accepted: 01/11/2022] [Indexed: 11/01/2022]
Abstract
Readmission to the intensive care unit (ICU) during the index hospitalization is associated with poor outcomes in medical or surgical ICU survivors. Little is known about critically ill patients with acute cardiovascular conditions cared for in a cardiac intensive care unit (CICU). We sought to describe the incidence, risk factors, and outcomes of all ICU readmissions in patients who survived to CICU discharge. We retrospectively reviewed Mayo Clinic patients from 2007 to 2015 who survived the index CICU admission and identified patients with a second ICU stay during their index hospitalization; these patients were categorized as ICU transfers (patients who went directly from the CICU to another ICU) or ICU readmissions (patients initially transferred from the CICU to the ward, and then back to an ICU). Among 9,434 CICU survivors (mean age 67 years), 138 patients (1.5%) had a second ICU stay during the index hospitalization: 60 ICU transfers (0.6%) and 78 ICU readmissions (0.8%). The most common indications for ICU readmission were respiratory failure and procedure/surgery. On multivariable modeling, respiratory failure, severe acute kidney injury, and Charlson Comorbidity Index at the time of discharge from the index ICU stay were associated with ICU readmission. Death during the first ICU readmission (n = 78) occurred in 7.7% of patients. In-hospital mortality was higher for patients with a second ICU stay. In conclusion, few CICU survivors have a second ICU stay during their index hospitalization; these patients are at a higher risk of in-hospital and 1-year mortality. Respiratory failure, severe acute kidney injury, and higher co-morbidity burden identify CICU survivors at elevated risk of ICU readmission.
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Affiliation(s)
- Mitchell Padkins
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alexander Fanaroff
- Department of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Courtney Bennett
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Brandon Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta
| | - Jason N Katz
- Department of Cardiovascular Disease and Department of Medicine, Duke University, Durham, North Carolina
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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47
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Fagundes A, Berg DD, Bohula EA, Baird-Zars VM, Barnett CF, Carnicelli AP, Chaudhry SP, Guo J, Keeley EC, Kenigsberg BB, Menon V, Miller PE, Newby LK, van Diepen S, Morrow DA, Katz JN. End-of-life care in the cardiac intensive care unit: a contemporary view from the Critical Care Cardiology Trials Network (CCCTN) Registry. Eur Heart J Acute Cardiovasc Care 2022; 11:190-197. [PMID: 34986236 DOI: 10.1093/ehjacc/zuab121] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 06/14/2023]
Abstract
AIMS Increases in life expectancy, comorbidities, and survival with complex cardiovascular conditions have changed the clinical profile of the patients in cardiac intensive care units (CICUs). In this environment, palliative care (PC) services are increasingly important. However, scarce information is available about the delivery of PC in CICUs. METHODS AND RESULTS The Critical Care Cardiology Trials Network (CCCTN) Registry is a network of tertiary care CICUs in North America. Between 2017 and 2020, up to 26 centres contributed an annual 2-month snapshot of all consecutive medical CICU admissions. We captured code status at admission and the decision for comfort measures only (CMO) before all deaths in the CICU. Of 13 422 patients, 10% died in the CICU and 2.6% were discharged to palliative hospice. Of patients who died in the CICU, 68% were CMO at death. In the CMO group, only 13% were do not resuscitate/do not intubate at admission. The median time from CICU admission to CMO decision was 3.4 days (25th-75th percentiles: 1.2-7.7) and ≥7 days in 27%. Time from CMO decision to death was <24 h in 88%, with a median of 3.8 h (25th-75th 1.0-10.3). Before a CMO decision, 78% received mechanical ventilation and 26% mechanical circulatory support. A PC provider team participated in the care of 41% of patients who died. CONCLUSIONS In a contemporary CICU registry, comfort measures preceded death in two-thirds of cases, frequently without PC involvement. The high utilization of advanced intensive care unit therapies and lengthy times to a CMO decision highlight a potential opportunity for early engagement of PC teams in CICU.
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Affiliation(s)
- Antonio Fagundes
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - David D Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Vivian M Baird-Zars
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Christopher F Barnett
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, DC, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Anthony P Carnicelli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Jianping Guo
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Ellen C Keeley
- Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - Benjamin B Kenigsberg
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington, DC, USA
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - L Kristin Newby
- Divison of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women's Hospital, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
| | - Jason N Katz
- Divison of Cardiology, Duke University School of Medicine, Durham, NC, USA
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48
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (S.V.)
| | - Jason N Katz
- Division of Cardiovascular Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC (J.N.K.)
| | - Venu Menon
- Section of Clinical Cardiology, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, OH (V.M.)
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49
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O'Brien CG, Barnett CF, Dudzinski DM, Sanchez PA, Katz JN, Harold JG, Hennessey EK, Mohabir PK. Training in Critical Care Cardiology Within Critical Care Medicine Fellowship: A Novel Pathway. J Am Coll Cardiol 2022; 79:609-613. [PMID: 35144752 DOI: 10.1016/j.jacc.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 01/21/2023]
Affiliation(s)
- Connor G O'Brien
- Department of Medicine, Division of Cardiology, University of California-San Francisco School of Medicine, San Francisco, California, USA.
| | - Christopher F Barnett
- Department of Medicine, Division of Cardiology, University of California-San Francisco School of Medicine, San Francisco, California, USA
| | - David M Dudzinski
- Department of Medicine, Division of Cardiology and Heart Center Intensive Care Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Pablo A Sanchez
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jason N Katz
- Department of Medicine, Division of Cardiovascular Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - John G Harold
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Erin K Hennessey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Paul K Mohabir
- Department of Medicine, Division of Allergy, Critical Care, and Pulmonary Medicine, Stanford University School of Medicine, Stanford, California, USA
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50
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Carnicelli AP, Blumer V, Genovese L, Gage A, Agarwal R, Lakdawala NK, Bohula E, Katz JN. The Road Not Yet Traveled: Distinction in Critical Care Cardiology through the Advanced Heart Failure and Transplant Cardiology Training Pathway. J Card Fail 2022; 28:339-342. [PMID: 35148880 DOI: 10.1016/j.cardfail.2021.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/27/2021] [Accepted: 07/30/2021] [Indexed: 11/30/2022]
Abstract
As the acuity, complexity, and illness severity of patients admitted to cardiac intensive care units have increased, the need to recognize critical care cardiology (CCC) as a dedicated subspecialty in cardiovascular disease has received increasing support. Differing viewpoints exist regarding the optimal pathway for CCC training. Currently, all proposed CCC training pathways involve permutations of individual training years culminating in subspecialty certification across multiple disciplines; however, there are significant disadvantages to these training paradigms. We propose an innovative, pragmatic approach to CCC training through tailored subspecialty training in advanced heart failure and transplant cardiology (AHFTC), using elective time to enrich AHFTC training with skills and experiences necessary to become a highly skilled critical care cardiologist. The completion of this pathway would lead to completion of AHFTC training with a novel designation: distinction in critical care cardiology.
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Affiliation(s)
- Anthony P Carnicelli
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
| | - Vanessa Blumer
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
| | - Leonard Genovese
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Ann Gage
- Centennial Heart, Centennial Medical Center, Nashville, Tennessee
| | - Richa Agarwal
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
| | - Neal K Lakdawala
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Erin Bohula
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jason N Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina.
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