1
|
Lopez MP, Applefeld W, Miller E, Elliott A, Bennett C, Lee B, Barnett C, Solomon MA, Corradi F, Sionis A, Mireles-Cabodevila E, Tavazzi G, Alviar CL. Complex Heart-Lung Ventilator Emergencies in the CICU. Cardiol Clin 2024; 42:253-271. [PMID: 38631793 DOI: 10.1016/j.ccl.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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
This review aims to enhance the comprehension and management of cardiopulmonary interactions in critically ill patients with cardiovascular disease undergoing mechanical ventilation. Highlighting the significance of maintaining a delicate balance, this article emphasizes the crucial role of adjusting ventilation parameters based on both invasive and noninvasive monitoring. It provides recommendations for the induction and liberation from mechanical ventilation. Special attention is given to the identification of auto-PEEP (positive end-expiratory pressure) and other situations that may impact hemodynamics and patients' outcomes.
Collapse
Affiliation(s)
- Mireia Padilla Lopez
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Willard Applefeld
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Elliott Miller
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Andrea Elliott
- Division of Cardiology, University of Minnesota, Minneapolis, MN, USA
| | - Courtney Bennett
- Heart and Vascular Institute, Leigh Valley Health Network, Allentown, PA, USA
| | - Burton Lee
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MA, USA
| | - Christopher Barnett
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Michael A Solomon
- Clinical Center and Cardiology Branch, Critical Care Medicine Department, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MA, USA
| | - Francesco Corradi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Sionis
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eduardo Mireles-Cabodevila
- Respiratory Institute, Cleveland Clinic, Ohio and the Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Guido Tavazzi
- Department of Critical Care Medicine, Intensive Care Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlos L Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University School of Medicine, USA.
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Miller PE, Huber K, Bohula EA, Krychtiuk KA, Pöss J, Roswell RO, Tavazzi G, Solomon MA, Kristensen SD, Morrow DA. Research Priorities in Critical Care Cardiology: JACC Expert Panel. J Am Coll Cardiol 2023; 82:2329-2337. [PMID: 38057075 PMCID: PMC10752230 DOI: 10.1016/j.jacc.2023.09.828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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: 05/30/2023] [Revised: 08/15/2023] [Accepted: 09/20/2023] [Indexed: 12/08/2023]
Abstract
Over the last several decades, the cardiac intensive care unit (CICU) has seen a substantial evolution in the patient population, comorbidities, and diagnoses. However, the generation of high-quality evidence to manage these complex and critically ill patients has been slow. Given the scarcity of clinical trials focused on critical care cardiology (CCC), CICU clinicians are often left to extrapolate from studies that either exclude or poorly represent the patient population admitted to CICUs. The lack of high-quality evidence and limited guidance from society guidelines has led to significant variation in practice patterns for many of the most common CICU diagnoses. Several barriers, both common to critical care research and unique to CCC, have impeded progress. In this multinational perspective, we describe key areas of priority for CCC research, current challenges for investigation in the CICU, and essential elements of a path forward for the field.
Collapse
Affiliation(s)
- P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Konstantin A Krychtiuk
- Department of Internal Medicine II, Division of Cardiology Medical University of Vienna, Vienna, Austria; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Janine Pöss
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Robert O Roswell
- Northwell Health, Zucker School of Medicine, Hempstead, New York, USA
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Intensive Care Fondazione Policlinico San Matteo Hospital IRCCS, Pavia, Italy
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Cardiovascular Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, USA
| | | | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, Baranowski B, Bergersen L, Chaudry HI, Coylewright M, Denktas AE, Gupta K, Gutierrez JA, Haft J, Hawkins BM, Herrmann HC, Kapur NK, Kilic S, Lesser J, Lin CH, Mendirichaga R, Nkomo VT, Park LG, Phoubandith DR, Quader N, Rich MW, Rosenfield K, Sabri SS, Shames ML, Shernan SK, Skelding KA, Tamis-Holland J, Thourani VH, Tremmel JA, Uretsky S, Wageman J, Welt F, Whisenant BK, White CJ, Yong CM, Mendes LA, Arrighi JA, Breinholt JP, Day J, Dec GW, Denktas AE, Drajpuch D, Faza N, Francis SA, Hahn RT, Housholder-Hughes SD, Khan SS, Kondapaneni MD, Lee KS, Lin CH, Hussain Mahar J, McConnaughey S, Niazi K, Pearson DD, Punnoose LR, Reejhsinghani RS, Ryan T, Silvestry FE, Solomon MA, Spicer RL, Weissman G, Werns SW. 2023 ACC/AHA/SCAI advanced training statement on interventional cardiology (coronary, peripheral vascular, and structural heart interventions): A report of the ACC Competency Management Committee. J Thorac Cardiovasc Surg 2023; 166:e73-e123. [PMID: 37269254 DOI: 10.1016/j.jtcvs.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
|
8
|
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.
Collapse
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
| | | |
Collapse
|
9
|
Jentzer JC, Noseworthy PA, Kashou AH, May AM, Chrispin J, Kabra R, Arps K, Blumer V, Tisdale JE, Solomon MA. Multidisciplinary Critical Care Management of Electrical Storm: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 81:2189-2206. [PMID: 37257955 PMCID: PMC10683004 DOI: 10.1016/j.jacc.2023.03.424] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 02/16/2023] [Accepted: 03/14/2023] [Indexed: 06/02/2023]
Abstract
Electrical storm (ES) reflects life-threatening cardiac electrical instability with 3 or more ventricular arrhythmia episodes within 24 hours. Identification of underlying arrhythmogenic cardiac substrate and reversible triggers is essential, as is interrogation and programming of an implantable cardioverter-defibrillator, if present. Medical management includes antiarrhythmic drugs, beta-adrenergic blockade, sedation, and hemodynamic support. The initial intensity of these interventions should be matched to the severity of ES using a stepped-care algorithm involving escalating treatments for higher-risk presentations or recurrent ventricular arrhythmias. Many patients with ES are considered for catheter ablation, which may require the use of temporary mechanical circulatory support. Outcomes after ES are poor, including frequent ES recurrences and deaths caused by progressive heart failure and other cardiac causes. A multidisciplinary collaborative approach to the management of ES is crucial, and evaluation for heart transplantation or palliative care is often appropriate, even for patients who survive the initial episode.
Collapse
Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Anthony H Kashou
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Adam M May
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rajesh Kabra
- Kansas City Heart Rhythm Institute, Overland Park, Kansas, USA
| | - Kelly Arps
- Cardiac Electrophysiology Section, Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Vanessa Blumer
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - James E Tisdale
- College of Pharmacy, Purdue University, West Lafayette, Indiana, USA; School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, Maryland, USA; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
10
|
Dougherty EJ, Chen LY, Awad KS, Ferreyra GA, Demirkale CY, Keshavarz A, Gairhe S, Johnston KA, Hicks ME, Sandler AB, Curran CS, Krack JM, Ding Y, Suffredini AF, Solomon MA, Elinoff JM, Danner RL. Inflammation and DKK1-induced AKT activation contribute to endothelial dysfunction following NR2F2 loss. Am J Physiol Lung Cell Mol Physiol 2023; 324:L783-L798. [PMID: 37039367 DOI: 10.1152/ajplung.00171.2022] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
NR2F2 is expressed in endothelial cells (ECs) and Nr2f2 knockout produces lethal cardiovascular defects. In humans, reduced NR2F2 expression is associated with cardiovascular diseases including congenital heart disease and atherosclerosis. Here, NR2F2 silencing in human primary ECs led to inflammation, endothelial-to-mesenchymal transition (EndMT), proliferation, hypermigration, apoptosis-resistance, and increased production of reactive oxygen species. These changes were associated with STAT and AKT activation along with increased production of DKK1. Co-silencing DKK1 and NR2F2 prevented NR2F2-loss induced STAT and AKT activation and reversed EndMT. Serum DKK1 concentrations were elevated in patients with pulmonary arterial hypertension (PAH) and DKK1 was secreted by ECs in response to in vitro loss of either BMPR2 or CAV1, which are genetic defects associated with the development of PAH. In human primary ECs, NR2F2 suppressed DKK1, while its loss conversely induced DKK1 and disrupted endothelial homeostasis, promoting phenotypic abnormalities associated with pathologic vascular remodeling. Activating NR2F2 or blocking DKK1 may be useful therapeutic targets for treating chronic vascular diseases associated with EC dysfunction.
Collapse
Affiliation(s)
- Edward J Dougherty
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Li-Yuan Chen
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Keytam S Awad
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Gabriela A Ferreyra
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Cumhur Y Demirkale
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Ali Keshavarz
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Salina Gairhe
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Kathryn A Johnston
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Madelyn E Hicks
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Alexis B Sandler
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Colleen S Curran
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Janell M Krack
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Yi Ding
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Anthony F Suffredini
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Jason M Elinoff
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Robert L Danner
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, United States
| |
Collapse
|
11
|
Namburar S, Banna S, Schenck C, Shahu A, Thomas AW, Ali T, Barnett CF, Solomon MA, Miller PE. IN HOSPITAL MORTALITY IN PATIENTS PRESENTING WITH ACUTE MYOCARDIAL INFARCTION NEEDING INVASIVE VENTILATION ADMITTED TO MICU VS. CICU. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01674-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
|
12
|
Ford V, Wang J, Applefeld W, Sun J, Solomon MA, Danner RL, Solomon S, Chen MY, Natanson C. NON-SURVIVORS IN EXPERIMENTAL SEPTIC SHOCK EXHIBIT LV EDEMA AND THE ABSENCE OF LV DILATATION. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01155-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
|
13
|
Alviar CL, Miller PE, Van Diepen S, Jentzer JC, Rampersad P, Hollenberg SM, Metkus TS, Fordyce C, Theriot P, Quien M, Sinha SS, Barnett CF, Roswell R, Morrow DA, Solomon MA. WHAT ARE THE CURRENT PRACTICE PATTERNS AND PERCEPTIONS OF CARDIOLOGISTS AND FELLOWS-IN-TRAINING IN MANAGING POSITIVE PRESSURE VENTILATION IN THE CARDIAC INTENSIVE CARE UNIT? J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02829-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Brusca SB, Elinoff JM, Zou Y, Jang MK, Kong H, Demirkale CY, Sun J, Seifuddin F, Pirooznia M, Valantine HA, Tanba C, Chaturvedi A, Graninger GM, Harper B, Chen LY, Cole J, Kanwar M, Benza RL, Preston IR, Agbor-Enoh S, Solomon MA. Plasma Cell-Free DNA Predicts Survival and Maps Specific Sources of Injury in Pulmonary Arterial Hypertension. Circulation 2022; 146:1033-1045. [PMID: 36004627 PMCID: PMC9529801 DOI: 10.1161/circulationaha.121.056719] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 08/05/2021] [Accepted: 07/15/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cell-free DNA (cfDNA) is a noninvasive marker of cellular injury. Its significance in pulmonary arterial hypertension (PAH) is unknown. METHODS Plasma cfDNA was measured in 2 PAH cohorts (A, n=48; B, n=161) and controls (n=48). Data were collected for REVEAL 2.0 (Registry to Evaluate Early and Long-Term PAH Disease Management) scores and outcome determinations. Patients were divided into the following REVEAL risk groups: low (≤6), medium (7-8), and high (≥9). Total cfDNA concentrations were compared among controls and PAH risk groups by 1-way analysis of variance. Log-rank tests compared survival between cfDNA tertiles and REVEAL risk groups. Areas under the receiver operating characteristic curve were estimated from logistic regression models. A sample subset from cohort B (n=96) and controls (n=16) underwent bisulfite sequencing followed by a deconvolution algorithm to map cell-specific cfDNA methylation patterns, with concentrations compared using t tests. RESULTS In cohort A, median (interquartile range) age was 62 years (47-71), with 75% female, and median (interquartile range) REVEAL 2.0 was 6 (4-9). In cohort B, median (interquartile range) age was 59 years (49-71), with 69% female, and median (interquartile range) REVEAL 2.0 was 7 (6-9). In both cohorts, cfDNA concentrations differed among patients with PAH of varying REVEAL risk and controls (analysis of variance P≤0.002) and were greater in the high-risk compared with the low-risk category (P≤0.002). In cohort B, death or lung transplant occurred in 14 of 54, 23 of 53, and 35 of 54 patients in the lowest, middle, and highest cfDNA tertiles, respectively. cfDNA levels stratified as tertiles (log-rank: P=0.0001) and REVEAL risk groups (log-rank: P<0.0001) each predicted transplant-free survival. The addition of cfDNA to REVEAL improved discrimination (area under the receiver operating characteristic curve, 0.72-0.78; P=0.02). Compared with controls, methylation analysis in patients with PAH revealed increased cfDNA originating from erythrocyte progenitors, neutrophils, monocytes, adipocytes, natural killer cells, vascular endothelium, and cardiac myocytes (Bonferroni adjusted P<0.05). cfDNA concentrations derived from erythrocyte progenitor cells, cardiac myocytes, and vascular endothelium were greater in patients with PAH with high-risk versus low-risk REVEAL scores (P≤0.02). CONCLUSIONS Circulating cfDNA is elevated in patients with PAH, correlates with disease severity, and predicts worse survival. Results from cfDNA methylation analyses in patients with PAH are consistent with prevailing paradigms of disease pathogenesis.
Collapse
Affiliation(s)
- Samuel B Brusca
- Pulmonary Arterial Hypertension Section of the Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Department of Internal Medicine, Division of Cardiology, University of California, San Francisco, CA
| | - Jason M Elinoff
- Pulmonary Arterial Hypertension Section of the Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Yvette Zou
- Pulmonary Arterial Hypertension Section of the Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Moon Kyoo Jang
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, MD
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, MD
| | - Hyesik Kong
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, MD
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, MD
| | - Cumhur Y Demirkale
- Pulmonary Arterial Hypertension Section of the Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Junfeng Sun
- Pulmonary Arterial Hypertension Section of the Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Fayaz Seifuddin
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, MD
| | - Mehdi Pirooznia
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, MD
| | - Hannah A Valantine
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, MD
- Department of Internal Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Carl Tanba
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - Abhishek Chaturvedi
- Pauley Heart Center, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Grace M Graninger
- Pulmonary Arterial Hypertension Section of the Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Bonnie Harper
- Pulmonary Arterial Hypertension Section of the Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Li-Yuan Chen
- Pulmonary Arterial Hypertension Section of the Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Justine Cole
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, MD
| | - Manreet Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA
| | - Raymond L Benza
- Departent of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ioana R Preston
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA
| | - Sean Agbor-Enoh
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, MD
- Genomic Research Alliance for Transplantation (GRAfT), Bethesda, MD
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael A Solomon
- Pulmonary Arterial Hypertension Section of the Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Cardiology Branch, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, MD
| |
Collapse
|
18
|
Brusca SB, Galiatsatos P, Warner S, Li X, Powell-Wiley TM, Kadri SS, Solomon MA. Outcomes of Patients With Primary Cardiac Diagnoses Admitted to Cardiac vs Noncardiac Intensive Care Units. JACC Adv 2022; 1:100114. [PMID: 36466046 PMCID: PMC9718493 DOI: 10.1016/j.jacadv.2022.100114] [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] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Demographics in cardiac intensive care units (CICUs) have evolved, with increased prevalence of noncardiac critical illnesses. OBJECTIVES This study compares outcomes of patients with primary cardiac diagnoses admitted to CICUs vs those of patients with primary cardiac diagnoses admitted to noncardiac ICUs. METHODS The Cerner Health Facts Database was queried to identify adults with primary cardiac diagnoses admitted to ICUs within 48 hours of presentation between 2009 and 2014. Only hospitals with multiple ICUs including a CICU were studied. Information on ICU staffing was not available. A univariate analysis of ICU type (model 1) and multivariate analyses incorporating patient- and hospital-level variables (model 2) and concurrent, noncardiac, ICU-level diagnoses (model 3) were utilized to assess the impact of ICU type on inpatient mortality. RESULTS Of 16,163 encounters across 14 hospitals, 8,499 (52.6%) were admitted to CICUs and 7,664 (47.4%) to noncardiac ICUs. Univariate analysis (model 1) demonstrated increased mortality in noncardiac ICUs compared to CICUs (odds ratio [OR]: 1.47, 95% CI: 1.32-1.64; P < 0.0001). This risk dissipated (OR: 1.04, 95% CI: 0.91-1.18; P = 0.56) after controlling for patient- and hospital-level variables (model 2). Inclusion of concurrent, noncardiac, ICU-level diagnoses (model 3) lead to a reversal with decreased mortality in noncardiac ICUs (OR: 0.86, 95% CI: 0.76-0.98; P = 0.03). CONCLUSIONS In this historical cohort study evaluating CICU outcomes prior to the evolution of proposed staffing and care model modernization, survival of cardiac patients with concurrent, noncardiac critical illnesses may have been better with the expertise available in general system ICUs. These results may support contemporary efforts to increase the capacity to manage noncardiac critical illnesses in CICUs.
Collapse
Affiliation(s)
- Samuel B. Brusca
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, California, USA
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sarah Warner
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Xiaobai Li
- Biostatistics and Epidemiology Service, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Tiffany M. Powell-Wiley
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
- Intramural Research Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland, USA
| | - Sameer S. Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Michael A. Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Ali T, Grimshaw A, Thomas AW, Solomon MA, Krumholz HM, Ross JS, Miller PE. UNDERREPRESENTATION AND EXCLUSION OF PATIENTS WITH CARDIOVASCULAR DISEASE IN INTENSIVE CARE RANDOMIZED CONTROL TRIALS. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01509-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
21
|
Ford V, Applefeld W, Wang J, Sun J, Feng J, Danner RL, Solomon SB, Chen MY, Sidenko S, Sachdev V, Solomon MA, Yu ZX, Natanson C. EARLY EPINEPHRINE INFUSION PREVENTS LATE MYOCARDIAL DEPRESSION AND ACCELERATES CARDIAC RECOVERY IN A LARGE ANIMAL MODEL OF SEPTIC SHOCK. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01262-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
22
|
Lu M, Chen LY, Gairhe S, Mazer AJ, Anderson SA, Nelson JN, Noguchi A, Siddique MAH, Dougherty EJ, Zou Y, Johnston KA, Yu ZX, Wang H, Wang S, Sun J, Solomon SB, Vanderpool RR, Solomon MA, Danner RL, Elinoff JM. Mineralocorticoid receptor antagonist treatment of established pulmonary arterial hypertension improves interventricular dependence in the SU5416-hypoxia rat model. Am J Physiol Lung Cell Mol Physiol 2022; 322:L315-L332. [PMID: 35043674 PMCID: PMC8858673 DOI: 10.1152/ajplung.00238.2021] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Treatment with mineralocorticoid receptor (MR) antagonists beginning at the outset of disease, or early thereafter, prevents pulmonary vascular remodeling in preclinical models of pulmonary arterial hypertension (PAH). However, the efficacy of MR blockade in established disease, a more clinically relevant condition, remains unknown. Therefore, we investigated the effectiveness of two MR antagonists, eplerenone (EPL) and spironolactone (SPL), after the development of severe right ventricular (RV) dysfunction in the rat SU5416-hypoxia (SuHx) PAH model. Cardiac magnetic resonance imaging (MRI) in SuHx rats at the end of week 5, before study treatment, confirmed features of established disease including reduced RV ejection fraction and RV hypertrophy, pronounced septal flattening with impaired left ventricular filling and reduced cardiac index. Five weeks of treatment with either EPL or SPL improved left ventricular filling and prevented the further decline in cardiac index compared with placebo. Interventricular septal displacement was reduced by EPL whereas SPL effects were similar, but not significant. Although MR antagonists did not significantly reduce pulmonary artery pressure or vessel remodeling in SuHx rats with established disease, animals with higher drug levels had lower pulmonary pressures. Consistent with effects on cardiac function, EPL treatment tended to suppress MR and proinflammatory gene induction in the RV. In conclusion, MR antagonist treatment led to modest, but consistent beneficial effects on interventricular dependence after the onset of significant RV dysfunction in the SuHx PAH model. These results suggest that measures of RV structure and/or function may be useful endpoints in clinical trials of MR antagonists in patients with PAH.
Collapse
Affiliation(s)
- Mengyun Lu
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Li-Yuan Chen
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Salina Gairhe
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Adrien J. Mazer
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Stasia A. Anderson
- 2Animal MRI Core Facility, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Jasmine N.H. Nelson
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Audrey Noguchi
- 3Murine Phenotyping Core, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Edward J. Dougherty
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Yvette Zou
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Kathryn A. Johnston
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Zu-Xi Yu
- 4Pathology Core Facility, National Heart, Lung, and Blood
Institute, National Institutes of Health, Bethesda, Maryland
| | - Honghui Wang
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Shuibang Wang
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Junfeng Sun
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Steven B. Solomon
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Rebecca R. Vanderpool
- 6Department of Medicine and Biomedical Engineering, University of Arizona College of Medicine, Tucson, Arizona
| | - Michael A. Solomon
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland,5Cardiology Branch, National Heart, Lung, and Blood
Institute, National Institutes of Health, Bethesda, Maryland
| | - Robert L. Danner
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jason M. Elinoff
- 1Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
23
|
Brusca S, Galiatsatos P, Warner S, Li X, Powell-Wiley T, Kadri S, Solomon MA. COMPARING OUTCOMES OF PATIENTS WITH PRIMARY CARDIAC DIAGNOSES ADMITTED TO CARDIAC AND NON-CARDIAC INTENSIVE CARE UNITS: AN ARGUMENT FOR THE EVOLUTION OF CICU STAFFING MODELS. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02843-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
24
|
Patel SM, Jentzer JC, Alviar CL, Baird-Zars VM, Barsness GW, Berg DD, Bohula EA, Daniels LB, DeFilippis AP, Keeley EC, Kontos MC, Lawler PR, Miller PE, Park JG, Roswell RO, Solomon MA, van Diepen S, Katz JN, Morrow DA. A pragmatic lab-based tool for risk assessment in cardiac critical care: data from the Critical Care Cardiology Trials Network (CCCTN) Registry. Eur Heart J Acute Cardiovasc Care 2022; 11:252-257. [PMID: 35134860 PMCID: PMC9123931 DOI: 10.1093/ehjacc/zuac012] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/11/2021] [Accepted: 01/24/2022] [Indexed: 02/05/2023]
Abstract
AIMS Contemporary cardiac intensive care unit (CICU) outcomes remain highly heterogeneous. As such, a risk-stratification tool using readily available lab data at time of CICU admission may help inform clinical decision-making. METHODS AND RESULTS The primary derivation cohort included 4352 consecutive CICU admissions across 25 tertiary care CICUs included in the Critical Care Cardiology Trials Network (CCCTN) Registry. Candidate lab indicators were assessed using multivariable logistic regression. An integer risk score incorporating the top independent lab indicators associated with in-hospital mortality was developed. External validation was performed in a separate CICU cohort of 9716 patients from the Mayo Clinic (Rochester, MN, USA). On multivariable analysis, lower pH [odds ratio (OR) 1.96, 95% confidence interval (CI) 1.72-2.24], higher lactate (OR 1.40, 95% CI 1.22-1.62), lower estimated glomerular filtration rate (OR 1.26, 95% CI 1.10-1.45), and lower platelets (OR 1.18, 95% CI 1.05-1.32) were the top four independent lab indicators associated with higher in-hospital mortality. Incorporated into the CCCTN Lab-Based Risk Score, these four lab indicators identified a 20-fold gradient in mortality risk with very good discrimination (C-index 0.82, 95% CI 0.80-0.84) in the derivation cohort. Validation of the risk score in a separate cohort of 3888 patients from the Registry demonstrated good performance (C-index of 0.82; 95% CI 0.80-0.84). Performance remained consistent in the external validation cohort (C-index 0.79, 95% CI 0.77-0.80). Calibration was very good in both validation cohorts (r = 0.99). CONCLUSION A simple integer risk score utilizing readily available lab indicators at time of CICU admission may accurately stratify in-hospital mortality risk.
Collapse
Affiliation(s)
- Siddharth M Patel
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, USA
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carlos L Alviar
- Division of Cardiology, Department of Medicine, NYU Langone Medical Center, New York, NY, 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, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, 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, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, 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, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, USA
| | - Lori B Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, CA, USA
| | - Andrew P DeFilippis
- Division of Cardiology, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Ellen C Keeley
- Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Michael C Kontos
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, 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 Elliott Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, 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, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, 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
| | - Sean van Diepen
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada,Division of Cardiology, Department of Critical Care, University of Alberta, Edmonton, AB, Canada
| | - Jason N Katz
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, 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, 60 Fenwood Rd, Suite 7022, Boston, MA 02115, USA,Corresponding author. Tel: +1 617 278 0181, Fax: +1 617 734 7329,
| | | |
Collapse
|
25
|
Yassine IA, Ghanem AM, Metwalli NS, Hamimi A, Ouwerkerk R, Matta JR, Solomon MA, Elinoff JM, Gharib AM, Abd-Elmoniem KZ. Native-resolution myocardial principal Eulerian strain mapping using convolutional neural networks and Tagged Magnetic Resonance Imaging. Comput Biol Med 2022; 141:105041. [PMID: 34836627 PMCID: PMC8900530 DOI: 10.1016/j.compbiomed.2021.105041] [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: 09/14/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Assessment of regional myocardial function at native pixel-level resolution can play a crucial role in recognizing the early signs of the decline in regional myocardial function. Extensive data processing in existing techniques limits the effective resolution and accuracy of the generated strain maps. The purpose of this study is to compute myocardial principal strain maps εp1 and εp2 from tagged MRI (tMRI) at the native image resolution using deep-learning local patch convolutional neural network (CNN) models (DeepStrain). METHODS For network training, validation, and testing, realistic tMRI datasets were generated and consisted of 53,606 cine images simulating the heart, the liver, blood pool, and backgrounds, including ranges of shapes, positions, motion patterns, noise, and strain. In addition, 102 in-vivo image datasets from three healthy subjects, and three Pulmonary Arterial Hypertension patients, were acquired and used to assess the network's in-vivo performance. Four convolutional neural networks were trained for mapping input tagging patterns to corresponding ground-truth principal strains using different cost functions. Strain maps using harmonic phase analysis (HARP) were obtained with various spectral filtering settings for comparison. CNN and HARP strain maps were compared at the pixel level versus the ground-truth and versus the least-loss in-vivo maps using Pearson correlation coefficients (R) and the median error and Inter-Quartile Range (IQR) histograms. RESULTS CNN-based local patch DeepStrain maps at a phantom resolution of 1.1mm × 1.1 mm and in-vivo resolution of 2.1mm × 1.6 mm were artifact-free with multiple fold improvement with εp1 ground-truth median error of 0.009(0.007) vs. 0.32(0.385) using HARP and εp2 ground-truth error of 0.016(0.021) vs. 0.181(0.08) using HARP. CNN-based strain maps showed substantially higher agreement with the ground-truth maps with correlation coefficients R > 0.91 for εp1 and εp2 compared to R < 0.21 and R < 0.82 for HARP-generated maps, respectively. CONCLUSION CNN-generated Eulerian strain mapping permits artifact-free visualization of myocardial function at the native image resolution.
Collapse
Affiliation(s)
- Inas A. Yassine
- Systems and Biomedical Engineering Department, Faculty of Engineering, Cairo University, Egypt
| | - Ahmed M. Ghanem
- Biomedical and Metabolic Imaging Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA
| | - Nader S. Metwalli
- Biomedical and Metabolic Imaging Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA
| | - Ahmed Hamimi
- Biomedical and Metabolic Imaging Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA
| | - Ronald Ouwerkerk
- Biomedical and Metabolic Imaging Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA
| | - Jatin R. Matta
- Biomedical and Metabolic Imaging Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA
| | - Michael A. Solomon
- Cardiovascular Branch of the National Heart, Lung, and Blood Institute (NHLBI), NIH, Bethesda, MD, USA.,Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | - Jason M. Elinoff
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | - Ahmed M. Gharib
- Biomedical and Metabolic Imaging Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA
| | - Khaled Z. Abd-Elmoniem
- Biomedical and Metabolic Imaging Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA,Corresponding author: Khaled Z Abd-Elmoniem, PhD, MHS, Biomedical and Metabolic Imaging Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Bldg. 10, CRC, Rm. 3-5340, Bethesda, MD 20892, Tel: 301-451-8982/Fax: 301-480-3166,
| |
Collapse
|
26
|
Jentzer JC, Wiley BM, Reddy YNV, Barnett C, Borlaug BA, Solomon MA. Epidemiology and outcomes of pulmonary hypertension in the cardiac intensive care unit. Eur Heart J Acute Cardiovasc Care 2022; 11:230-241. [PMID: 35064269 PMCID: PMC9123933 DOI: 10.1093/ehjacc/zuab127] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/14/2021] [Accepted: 12/21/2021] [Indexed: 01/24/2023]
Abstract
AIMS Pulmonary hypertension (PH) has been consistently associated with adverse outcomes in hospitalized patients. Limited epidemiologic data exist regarding PH in the cardiac intensive care unit (CICU) population. Here, we describe the prevalence, aetiology, and outcomes of PH in the CICU. METHODS AND RESULTS Cardiac intensive care unit patients admitted from 2007 to 2018 who had right ventricular systolic pressure (RVSP) measured via transthoracic echocardiography near CICU admission were included. PH was defined as RVSP >35 mmHg, and moderate-to-severe PH as RVSP ≥50 mmHg. Predictors of in-hospital mortality were determined using multivariable logistic regression. Among 5042 patients (mean age 69.4 ± 14.8 years; 41% females), PH was present in 3085 (61%). The majority (68%) of patients with PH had left heart failure, and 29% had lung disease. In-hospital mortality occurred in 8.3% and was more frequent in patients with PH [10.9% vs. 4.2%, adjusted odds ratio (OR) 1.40, 95% confidence interval (CI) 1.03-1.92, P = 0.03], particularly patients with moderate-to-severe PH (14.4% vs. 6.2%, adjusted OR 1.65, 95% CI 1.27-2.14, P < 0.001). In-hospital mortality increased incrementally as a function of higher RVSP (adjusted 1.18 per 10 mmHg increase, 95% CI 1.09-1.28, P < 0.001). Patients with higher RVSP or moderate-to-severe PH had increased in-hospital mortality across admission diagnoses (all P < 0.05). CONCLUSIONS Pulmonary hypertension is very common in the CICU population and appears to be independently associated with a higher risk of death during hospitalization, although the strength of this association varies according to the underlying admission diagnosis. These data highlight the importance of PH in patients with cardiac critical illness.
Collapse
Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA,Corresponding author. Tel: +1 507 255 2502, Fax: +1 507 255 2550,
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
| | - Christopher Barnett
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA,Cardiovascular Branch, National Heart Lung and Blood Institute, National Institutes of Health, Building 31, 31 Center Drive, Bethesda, MD 20892, USA
| |
Collapse
|
27
|
Bhatt AS, Berg DD, Bohula EA, Alviar CL, Baird-Zars VM, Barnett CF, Burke JA, Carnicelli AP, Chaudhry SP, Daniels LB, Fang JC, Fordyce CB, Gerber DA, Guo J, Jentzer JC, Katz JN, Keller N, Kontos MC, Lawler PR, Menon V, Metkus TS, Nativi-Nicolau J, Phreaner N, Roswell RO, Sinha SS, Jeffrey Snell R, Solomon MA, Van Diepen S, Morrow DA. De Novo vs Acute-on-Chronic Presentations of Heart Failure-Related Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry. J Card Fail 2021; 27:1073-1081. [PMID: 34625127 DOI: 10.1016/j.cardfail.2021.08.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [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: 06/07/2021] [Revised: 08/27/2021] [Accepted: 08/27/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Heart failure-related cardiogenic shock (HF-CS) accounts for an increasing proportion of cases of CS in contemporary cardiac intensive care units. Whether the chronicity of HF identifies distinct clinical profiles of HF-CS is unknown. METHODS AND RESULTS We evaluated admissions to cardiac intensive care units for HF-CS in 28 centers using data from the Critical Care Cardiology Trials Network registry (2017-2020). HF-CS was defined as CS due to ventricular failure in the absence of acute myocardial infarction and was classified as de novo vs acute-on-chronic based on the absence or presence of a prior diagnosis of HF, respectively. Clinical features, resource use, and outcomes were compared among groups. Of 1405 admissions with HF-CS, 370 had de novo HF-CS (26.3%), and 1035 had acute-on-chronic HF-CS (73.7%). Patients with de novo HF-CS had a lower prevalence of hypertension, diabetes, coronary artery disease, atrial fibrillation, and chronic kidney disease (all P < 0.01). Median Sequential Organ Failure Assessment (SOFA) scores were higher in those with de novo HF-CS (8; 25th-75th: 5-11) vs acute-on-chronic HF-CS (6; 25th-75th: 4-9, P < 0.01), as was the proportion of Society of Cardiovascular Angiography and Intervention (SCAI) shock stage E (46.1% vs 26.1%, P < 0.01). After adjustment for clinical covariates and preceding cardiac arrest, the risk of in-hospital mortality was higher in patients with de novo HF-CS than in those with acute-on-chronic HF-CS (adjusted hazard ratio 1.36, 95% confidence interval 1.05-1.75, P = 0.02). CONCLUSIONS Despite having fewer comorbidities, patients with de novo HF-CS had more severe shock presentations and worse in-hospital outcomes. Whether HF disease chronicity is associated with time-dependent compensatory adaptations, unique pathobiological features and responses to treatment in patients presenting with HF-CS warrants further investigation.
Collapse
Affiliation(s)
- Ankeet S Bhatt
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - 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
| | - 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
| | | | - 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
| | | | - James A Burke
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | | | | | - Lori B Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
| | | | - Christopher B Fordyce
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel A Gerber
- Cardiovascular Division, Department of Medicine, Stanford University, Stanford, California
| | - 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
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jason N Katz
- Division of Cardiology, Duke University, Durham, North Carolina
| | - Norma Keller
- New York University Langone Health, New York, New York
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Ontario, Canada
| | - Venu Menon
- Cleveland Clinic Coordinating Center for Clinical Research, Department of Cardiovascular Medicine, Cleveland, Ohio
| | - Thomas S Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Nicholas Phreaner
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
| | | | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia
| | | | - 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
| | - Sean Van Diepen
- Department of Critical Care and Division of Cardiology, 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.
| |
Collapse
|
28
|
Lu M, Blaine KP, Cullinane A, Hall C, Dulau-Florea A, Sun J, Chenwi HF, Graninger GM, Harper B, Thompson K, Krack J, Barnett CF, Brusca SB, Elinoff JM, Solomon MA. Pulmonary arterial hypertension patients display normal kinetics of clot formation using thrombelastography. Pulm Circ 2021; 11:20458940211022204. [PMID: 34249330 PMCID: PMC8237222 DOI: 10.1177/20458940211022204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/16/2021] [Indexed: 11/15/2022] Open
Abstract
Pulmonary arterial hypertension is characterized by endothelial dysfunction and
microthrombi formation. The role of anticoagulation remains controversial, with
studies demonstrating inconsistent effects on pulmonary arterial hypertension
mortality. Clinical anticoagulation practices are currently heterogeneous,
reflecting physician preference. This study uses thrombelastography and
hematology markers to evaluate whether clot formation and fibrinolysis are
abnormal in pulmonary arterial hypertension patients. Venous blood was collected
from healthy volunteers (n = 20) and patients with pulmonary
arterial hypertension (n = 20) on stable medical therapy for
thrombelastography analysis. Individual thrombelastography parameters and a
calculated coagulation index were used for comparison. In addition, hematologic
markers, including fibrinogen, factor VIII activity, von Willebrand factor
activity, von Willebrand factor antigen, and alpha2-antiplasmin, were measured
in pulmonary arterial hypertension patients and compared to healthy volunteers.
Between group differences were analyzed using t tests and linear mixed models,
accounting for repeated measures when applicable. Although the degree of
fibrinolysis (LY30) was significantly lower in pulmonary arterial hypertension
patients compared to healthy volunteers (0.3% ± 0.6 versus
1.3% ± 1.1, p = 0.04), all values were within the normal
reference range (0–8%). All other thrombelastography parameters were not
significantly different between pulmonary arterial hypertension patients and
healthy volunteers (p ≥ 0.15 for all). Similarly,
alpha2-antiplasmin activity levels were higher in pulmonary arterial
hypertension patients compared to healthy volunteers (103.7% ± 13.6
versus 82.6% ± 9.5, p < 0.0001), but
all individual values were within the normal range (75–132%). There were no
other significant differences in hematologic markers between pulmonary arterial
hypertension patients and healthy volunteers (p ≥ 0.07 for
all). Sub-group analysis comparing thrombelastography results in patients
treated with or without prostacyclin pathway targeted therapies were also
non-significant. In conclusion, treated pulmonary arterial hypertension patients
do not demonstrate abnormal clotting kinetics or fibrinolysis by
thrombelastography.
Collapse
Affiliation(s)
- Mengyun Lu
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Kevin P Blaine
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ann Cullinane
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Courtney Hall
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Alina Dulau-Florea
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Herman F Chenwi
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Grace M Graninger
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Bonnie Harper
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Keshia Thompson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Janell Krack
- Pharmacy Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Christopher F Barnett
- MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - Samuel B Brusca
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jason M Elinoff
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Michael A Solomon
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
29
|
Wiegers SE, Ryan T, Arrighi JA, Brown SM, Canaday B, Damp JB, Diaz-Gomez JL, Figueredo VM, Garcia MJ, Gillam LD, Griffin BP, Kirkpatrick JN, Klarich KW, Lui GK, Maffett S, Naqvi TZ, Patel AR, Poulin MF, Rose GA, Swaminathan M, Arrighi JA, Mendes LA, Adams JE, Brush JE, Dec GW, Denktas A, Fernandes S, Freeman R, Hahn RT, Halperin JL, Housholder-Hughes SD, Khan SS, Klarich KW, Lin CH, Marine JE, McPherson JA, Niazi K, Ryan T, Solomon MA, Spicer RL, Tam M, Wang A, Weissman G, Weitz HH, Williams ES. 2019 ACC/AHA/ASE Advanced Training Statement on Echocardiography (Revision of the 2003 ACC/AHA Clinical Competence Statement on Echocardiography): A Report of the ACC Competency Management Committee. J Am Soc Echocardiogr 2020; 32:919-943. [PMID: 31378259 DOI: 10.1016/j.echo.2019.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
30
|
Jentzer JC, Bihorac A, Brusca SB, Del Rio-Pertuz G, Kashani K, Kazory A, Kellum JA, Mao M, Moriyama B, Morrow DA, Patel HN, Rali AS, van Diepen S, Solomon MA. Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives. J Am Coll Cardiol 2020; 76:1084-1101. [PMID: 32854844 PMCID: PMC11032174 DOI: 10.1016/j.jacc.2020.06.070] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [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: 03/23/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.
Collapse
Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Azra Bihorac
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - Samuel B Brusca
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Gaspar Del Rio-Pertuz
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Amir Kazory
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, Florida
| | - John A Kellum
- Department of Critical Care Medicine and Center for Critical Care Nephrology, The CRISMA Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Brad Moriyama
- Department of Critical Care Medicine, Special Volunteer, National Institutes of Health, Bethesda, Maryland
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Hena N Patel
- Division of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Aniket S Rali
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
31
|
Brusca SB, Barnett C, Barnhart BJ, Weng W, Morrow DA, Soble JS, Katz JN, Wiley BM, van Diepen S, Gomez AD, Solomon MA. Role of Critical Care Medicine Training in the Cardiovascular Intensive Care Unit: Survey Responses From Dual Certified Critical Care Cardiologists. J Am Heart Assoc 2020; 8:e011721. [PMID: 30879373 PMCID: PMC6475069 DOI: 10.1161/jaha.118.011721] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 12/28/2022]
Abstract
Background Cardiovascular intensive care units ( CICUs ) have evolved from coronary care wards into distinct units for critically ill patients with primary cardiac diseases, often suffering from illnesses that cross multiple disciplines. Mounting evidence has demonstrated improved survival with the incorporation of dedicated CICU providers with expertise in critical care medicine ( CCM ). This is the first study to systematically survey dual certified physicians in order to assess the relevance of CCM training to contemporary CICU care. Methods and Results Utilizing American Board of Internal Medicine data through 2014, 397 eligible physicians had obtained initial certification in both cardiovascular disease and CCM . A survey to delineate the role of critical care training in the CICU was provided to these physicians. Among those surveyed, 120 physicians (30%) responded. Dual certified physicians reported frequent use of their CCM skills in the CICU , highlighting ventilator management, multiorgan dysfunction management, end-of-life care, and airway management. The majority (85%) cited these skills as the reason CCM training should be prioritized by future CICU providers. Few (17%) agreed that general cardiology fellowship alone is currently sufficient to care for patients in the modern CICU . Furthermore, there was a consensus that there is an unmet need for cardiologists trained in CCM (70%) and that CICU s should adopt a level system similar to trauma centers (61%). Conclusions Citing specific skills acquired during CCM training, dual certified critical care cardiologists reported that their additional critical care experience was necessary in their practice to effectively deliver care in the modern CICU .
Collapse
Affiliation(s)
- Samuel B Brusca
- 1 Critical Care Medicine Department National Institutes of Health Clinical Center Bethesda MD
| | - Christopher Barnett
- 2 Department of Cardiology Medstar Washington Hospital Center Washington DC.,3 Division of Cardiology Department of Medicine University of California San Francisco at Zuckerberg San Francisco General Hospital San Francisco CA
| | | | - Weifeng Weng
- 4 American Board of Internal Medicine Philadelphia PA
| | - David A Morrow
- 5 Levine Cardiac Intensive Care Unit Cardiovascular Division Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Jeffrey S Soble
- 6 Division of Cardiology Rush University Medical Center Chicago IL
| | - Jason N Katz
- 7 Division of Cardiology Department of Medicine & Surgery University of North Carolina Chapel Hill NC
| | - Brandon M Wiley
- 8 Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Sean van Diepen
- 9 Department of Critical Care Medicine and Division of Cardiology Department of Medicine University of Alberta Edmonton, Alberta Canada
| | - Antonio D Gomez
- 10 Division of Pulmonary and Critical Care Medicine Department of Medicine University of California San Francisco at Zuckerberg San Francisco General Hospital San Francisco CA
| | - Michael A Solomon
- 1 Critical Care Medicine Department National Institutes of Health Clinical Center Bethesda MD.,11 Cardiology Branch National Heart, Lung, and Blood Institute of the National Institutes of Health Bethesda MD
| |
Collapse
|
32
|
Bohula EA, Katz JN, van Diepen S, Alviar CL, Baird-Zars VM, Park JG, Barnett CF, Bhattal G, Barsness GW, Burke JA, Cremer PC, Cruz J, Daniels LB, DeFilippis A, Granger CB, Hollenberg S, Horowitz JM, Keller N, Kontos MC, Lawler PR, Menon V, Metkus TS, Ng J, Orgel R, Overgaard CB, Phreaner N, Roswell RO, Schulman SP, Snell RJ, Solomon MA, Ternus B, Tymchak W, Vikram F, Morrow DA. Demographics, Care Patterns, and Outcomes of Patients Admitted to Cardiac Intensive Care Units: The Critical Care Cardiology Trials Network Prospective North American Multicenter Registry of Cardiac Critical Illness. JAMA Cardiol 2020; 4:928-935. [PMID: 31339509 DOI: 10.1001/jamacardio.2019.2467] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [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: 12/27/2022]
Abstract
Importance Single-center and claims-based studies have described substantial changes in the landscape of care in the cardiac intensive care unit (CICU). Professional societies have recommended research to guide evidence-based CICU redesigns. Objective To characterize patients admitted to contemporary, advanced CICUs. Design, Setting, and Participants This study established the Critical Care Cardiology Trials Network (CCCTN), an investigator-initiated multicenter network of 16 advanced, tertiary CICUs in the United States and Canada. For 2 months in each CICU, data for consecutive admissions were submitted to the central data coordinating center (TIMI Study Group). The data were collected and analyzed between September 2017 and 2018. Main Outcomes and Measures Demographics, diagnoses, management, and outcomes. Results Of 3049 participants, 1132 (37.1%) were women, 797 (31.4%) were individuals of color, and the median age was 65 years (25th and 75th percentiles, 55-75 years). Between September 2017 and September 2018, 3310 admissions were included, among which 2557 (77.3%) were for primary cardiac problems, 337 (10.2%) for postprocedural care, 253 (7.7%) for mixed general and cardiac problems, and 163 (4.9%) for overflow from general medical ICUs. When restricted to the initial 2 months of medical CICU admissions for each site, the primary analysis population included 3049 admissions with a high burden of noncardiovascular comorbidities. The top 2 CICU admission diagnoses were acute coronary syndrome (969 [31.8%]) and heart failure (567 [18.6%]); however, the proportion of acute coronary syndrome was highly variable across centers (15%-57%). The primary indications for CICU care included respiratory insufficiency (814 [26.7%]), shock (643 [21.1%]), unstable arrhythmia (521 [17.1%]), and cardiac arrest (265 [8.7%]). Advanced CICU therapies or monitoring were required for 1776 patients (58.2%), including intravenous vasoactive medications (1105 [36.2%]), invasive hemodynamic monitoring (938 [30.8%]), and mechanical ventilation (652 [21.4%]). The overall CICU mortality rate was 8.3% (95% CI, 7.3%-9.3%). The CICU indications that were associated with the highest mortality rates were cardiac arrest (101 [38.1%]), cardiogenic shock (140 [30.6%]), and the need for renal replacement therapy (51 [34.5%]). Notably, patients admitted solely for postprocedural observation or frequent monitoring had a mortality rate of 0.2% to 0.4%. Conclusions and Relevance In a contemporary network of tertiary care CICUs, respiratory failure and shock predominated indications for admission and carried a poor prognosis. While patterns of practice varied considerably between centers, a substantial, low-risk population was identified. Multicenter collaborative networks, such as the CCCTN, could be used to help redesign cardiac critical care and to test new therapeutic strategies.
Collapse
Affiliation(s)
- Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jason N Katz
- University of North Carolina at Chapel Hill, Chapel Hill
| | - Sean van Diepen
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Vivian M Baird-Zars
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeong-Gun Park
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - James A Burke
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | | | | | - Lori B Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla
| | | | | | | | | | | | | | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Venu Menon
- Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - Jason Ng
- New York University Langone Health, New York
| | - Ryan Orgel
- University of North Carolina at Chapel Hill, Chapel Hill
| | - Christopher B Overgaard
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nicholas Phreaner
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla
| | | | | | | | - Michael A Solomon
- Clinical Center and Cardiology Branch, Critical Care Medicine Department, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Wayne Tymchak
- Division of Cardiology, Department of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Fnu Vikram
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
33
|
Katz JN, Sinha SS, Alviar CL, Dudzinski DM, Gage A, Brusca SB, Flanagan MC, Welch T, Geller BJ, Miller PE, Leonardi S, Bohula EA, Price S, Chaudhry SP, Metkus TS, O'Brien CG, Sionis A, Barnett CF, Jentzer JC, Solomon MA, Morrow DA, van Diepen S. COVID-19 and Disruptive Modifications to Cardiac Critical Care Delivery: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 76:72-84. [PMID: 32305402 PMCID: PMC7161519 DOI: 10.1016/j.jacc.2020.04.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 12/12/2022]
Abstract
The COVID-19 pandemic has presented a major unanticipated stress on the workforce, organizational structure, systems of care, and critical resource supplies. To ensure provider safety, to maximize efficiency, and to optimize patient outcomes, health systems need to be agile. Critical care cardiologists may be uniquely positioned to treat the numerous respiratory and cardiovascular complications of the SARS-CoV-2 and support clinicians without critical care training who may be suddenly asked to care for critically ill patients. This review draws upon the experiences of colleagues from heavily impacted regions of the United States and Europe, as well as lessons learned from military mass casualty medicine. This review offers pragmatic suggestions on how to implement scalable models for critical care delivery, cultivate educational tools for team training, and embrace technologies (e.g., telemedicine) to enable effective collaboration despite social distancing imperatives.
Collapse
Affiliation(s)
- Jason N Katz
- Division of Cardiology, Duke University, Durham, North Carolina.
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia. https://twitter.com/ShashankSinhaMD
| | - Carlos L Alviar
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center NYU Langone Medical Center, New York, New York
| | - David M Dudzinski
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ann Gage
- Division of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | - Samuel B Brusca
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - M Casey Flanagan
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia
| | - Timothy Welch
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, Virginia; Virginia Heart, Falls Church, Virginia
| | - Bram J Geller
- Division of Cardiology, Maine Medical Center, Portland, Maine
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Sergio Leonardi
- Coronary Care Unit and Laboratory of Clinical and Experimental Cardiology-Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Susanna Price
- Royal Brompton and Harefield NHS Foundation Trust, Royal Brompton Hospital, London, United Kingdom
| | | | - Thomas S Metkus
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Connor G O'Brien
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-SantPaul, Universidad Autonoma de Barcelona, Barcelona, Spain
| | | | - Jacob C Jentzer
- Department of Cardiovascular Medicine and Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael A Solomon
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - David A Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta Hospital, Alberta, Canada. https://twitter.com/seanvandiepen
| |
Collapse
|
34
|
Yancy CW, Drazner MH, Coffin ST, Cornwell W, Desai S, Erwin JP, Ginwalla M, Harshaw-Ellis KS, Horwich T, Kittleson M, Lala A, Lewsey SC, Marine JE, Martin C, Meehan K, Morrow DA, Schlendorf K, Smith JW, Stevens GR, Arrighi JA, Mendes LA, Adams JE, Brush JE, Dec GW, Denktas A, Fernandes S, Freeman R, Francis SA, Hahn RT, Halperin JL, Housholder-Hughes SD, Khan SS, Klarich K, Lin CH, Marine JE, McPherson JA, Niazi K, Ryan T, Solomon MA, Spicer RL, Tam M, Wang A, Weissman G, Weitz HH, Williams ES. 2020 ACC/HFSA/ISHLT Lifelong Learning Statement for Advanced Heart Failure and Transplant Cardiology Specialists: A Report of the ACC Competency Management Committee. J Card Fail 2020; 26:254-269. [PMID: 32081473 DOI: 10.1016/j.cardfail.2020.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
35
|
Rali AS, Chandler J, Sauer A, Solomon MA, Shah Z. Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock: Lifeline of Modern Day CICU. J Intensive Care Med 2019; 36:290-303. [PMID: 31830842 DOI: 10.1177/0885066619894541] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cardiogenic shock (CS) portends an extremely high mortality of nearly 50% during index hospitalization. Prompt diagnoses of CS, its underlying etiology, and efficient implementation of treatment modalities, including mechanical circulatory support (MCS), are critical especially in light of such high predicted mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides the most comprehensive cardiopulmonary support in critically ill patients and hence has seen a steady increase in its utilization over the past decade. Hence, a good understanding of VA-ECMO, its role in treatment of CS, especially when compared with other temporary MCS devices, and its complications are vital for any critical care cardiologist. Our review of VA-ECMO aims to provide the same.
Collapse
Affiliation(s)
- Aniket S Rali
- Department of Cardiovascular Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
| | - Jonathan Chandler
- Department of Internal Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
| | - Andrew Sauer
- Department of Cardiovascular Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
| | - Michael A Solomon
- Critical Care Medicine, 2511National Institutes of Health Clinical Center, Bethesda, MD, USA.,Cardiology Branch, National Heart, Lung, and Blood Institute, 2511National Institutes of Health, Bethesda, MD, USA
| | - Zubair Shah
- Department of Cardiovascular Medicine, 12251The University of Kansas Health System, Kansas City, KS, USA
| |
Collapse
|
36
|
Berg DD, Barnett CF, Kenigsberg BB, Papolos A, Alviar CL, Baird-Zars VM, Barsness GW, Bohula EA, Brennan J, Burke JA, Carnicelli AP, Chaudhry SP, Cremer PC, Daniels LB, DeFilippis AP, Gerber DA, Granger CB, Hollenberg S, Horowitz JM, Gladden JD, Katz JN, Keeley EC, Keller N, Kontos MC, Lawler PR, Menon V, Metkus TS, Miller PE, Nativi-Nicolau J, Newby LK, Park JG, Phreaner N, Roswell RO, Schulman SP, Sinha SS, Snell RJ, Solomon MA, Teuteberg JJ, Tymchak W, van Diepen S, Morrow DA. Clinical Practice Patterns in Temporary Mechanical Circulatory Support for Shock in the Critical Care Cardiology Trials Network (CCCTN) Registry. Circ Heart Fail 2019; 12:e006635. [PMID: 31707801 DOI: 10.1161/circheartfailure.119.006635] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [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] [Indexed: 12/20/2022]
Abstract
BACKGROUND Temporary mechanical circulatory support (MCS) devices provide hemodynamic assistance for shock refractory to pharmacological treatment. Most registries have focused on single devices or specific etiologies of shock, limiting data regarding overall practice patterns with temporary MCS in cardiac intensive care units. METHODS The CCCTN (Critical Care Cardiology Trials Network) is a multicenter network of tertiary CICUs in North America. Between September 2017 and September 2018, each center (n=16) contributed a 2-month snapshot of consecutive medical CICU admissions. RESULTS Of the 270 admissions using temporary MCS, 33% had acute myocardial infarction-related cardiogenic shock (CS), 31% had CS not related to acute myocardial infarction, 11% had mixed shock, and 22% had an indication other than shock. Among all 585 admissions with CS or mixed shock, 34% used temporary MCS during the CICU stay with substantial variation between centers (range: 17%-50%). The most common temporary MCS devices were intraaortic balloon pumps (72%), Impella (17%), and veno-arterial extracorporeal membrane oxygenation (11%), although intraaortic balloon pump use also varied between centers (range: 40%-100%). Patients managed with intraaortic balloon pump versus other forms of MCS (advanced MCS) had lower Sequential Organ Failure Assessment scores and less severe metabolic derangements. Illness severity was similar at high- versus low-MCS utilizing centers and at centers with more advanced MCS use. CONCLUSIONS There is wide variation in the use of temporary MCS among patients with shock in tertiary CICUs. While hospital-level variation in temporary MCS device selection is not explained by differences in illness severity, patient-level variation appears to be related, at least in part, to illness severity.
Collapse
Affiliation(s)
- 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 (D.D.B., V.M.B.-Z., E.A.B., J.-G.P., D.A.M.)
| | - Christopher F Barnett
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington DC (C.F.B., B.B.K., A.P.)
| | - Benjamin B Kenigsberg
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington DC (C.F.B., B.B.K., A.P.)
| | - Alexander Papolos
- Medstar Heart and Vascular Institute, Medstar Washington Hospital Center, Washington DC (C.F.B., B.B.K., A.P.)
| | - Carlos L Alviar
- Leon H. Charney Division of Cardiology, New York University School of Medicine (C.L.A., J.M.H., N.K.)
| | - 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 (D.D.B., V.M.B.-Z., E.A.B., J.-G.P., D.A.M.)
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.D.G.)
| | - 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 (D.D.B., V.M.B.-Z., E.A.B., J.-G.P., D.A.M.)
| | - Joseph Brennan
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (J.B., P.E.M.)
| | - James A Burke
- Lehigh Valley Health Network, Allentown, PA (J.A.B.)
| | - Anthony P Carnicelli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.P.C., C.B.G., L.K.N.)
| | | | - Paul C Cremer
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, OH (P.C.C.)
| | - Lori B Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (L.B.D., N.P.)
| | | | - Daniel A Gerber
- Department of Medicine, Stanford University School of Medicine, CA (D.A.G., J.J.T.)
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.P.C., C.B.G., L.K.N.)
| | - Steven Hollenberg
- Department of Cardiovascular Disease, Cooper University Hospital, Camden, NJ (S.H.)
| | - James M Horowitz
- Leon H. Charney Division of Cardiology, New York University School of Medicine (C.L.A., J.M.H., N.K.)
| | - James D Gladden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (G.W.B., J.D.G.)
| | - Jason N Katz
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina, Center for Heart and Vascular Care, Chapel Hill (J.N.K.)
| | - Ellen C Keeley
- Division of Cardiology, University of Florida, Gainesville (E.C.K.)
| | - Norma Keller
- Leon H. Charney Division of Cardiology, New York University School of Medicine (C.L.A., J.M.H., N.K.)
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond (M.C.K.)
| | - Patrick R Lawler
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, ON (P.R.L.)
| | - Venu Menon
- Department of Cardiology, St Vincent Hospital, Indianapolis, IN (S.-P.C., V.M.)
| | - Thomas S Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (T.S.M., S.P.S.)
| | - P Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (J.B., P.E.M.)
| | - Jose Nativi-Nicolau
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City (J.N.-N.)
| | - L Kristin Newby
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.P.C., C.B.G., L.K.N.)
| | - 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, MA (D.D.B., V.M.B.-Z., E.A.B., J.-G.P., D.A.M.)
| | - Nicholas Phreaner
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (L.B.D., N.P.)
| | | | - Steven P Schulman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (T.S.M., S.P.S.)
| | - Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA (S.S.S.)
| | | | - 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 (M.A.S.)
| | - Jeffrey J Teuteberg
- Department of Medicine, Stanford University School of Medicine, CA (D.A.G., J.J.T.)
| | - Wayne Tymchak
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (W.T., S.v.D.)
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (W.T., S.v.D.)
| | - 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 (D.D.B., V.M.B.-Z., E.A.B., J.-G.P., D.A.M.)
| |
Collapse
|
37
|
Elinoff JM, Mazer AJ, Cai R, Lu M, Graninger G, Harper B, Ferreyra GA, Sun J, Solomon MA, Danner RL. Meta-analysis of blood genome-wide expression profiling studies in pulmonary arterial hypertension. Am J Physiol Lung Cell Mol Physiol 2019; 318:L98-L111. [PMID: 31617731 DOI: 10.1152/ajplung.00252.2019] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Inflammatory cell infiltrates are a prominent feature of aberrant vascular remodeling in pulmonary arterial hypertension (PAH), suggesting that immune effector cells contribute to disease progression. Genome-wide blood expression profiling studies have attempted to better define this inflammatory component of PAH pathobiology but have been hampered by small sample sizes, methodological differences, and very little gene-level reproducibility. The current meta-analysis (seven studies; 156 PAH patients/110 healthy controls) was performed to assess the comparability of data across studies and to possibly derive a generalizable transcriptomic signature. Idiopathic (IPAH) compared with disease-associated PAH (APAH) displayed highly similar expression profiles with no differentially expressed genes, even after substantially relaxing selection stringency. In contrast, using a false discovery rate of ≤1% and I2 < 40% (low-to-moderate heterogeneity across studies) both IPAH and APAH differed markedly from healthy controls with the combined PAH cohort yielding 1,269 differentially expressed, unique gene transcripts. Bioinformatic analyses, including gene-set enrichment, which uses all available data independent of gene selection thresholds, identified interferon, mammalian target of rapamycin/p70S6K, stress kinase, and Toll-like receptor signaling as enriched mechanisms within the PAH gene signature. Enriched biological functions and diseases included tumorigenesis, autoimmunity, antiviral response, and cell death consistent with prevailing theories of PAH pathogenesis. Although otherwise indistinguishable, APAH (predominantly PAH due to systemic sclerosis) had a somewhat stronger interferon profile than IPAH. Meta-analysis defined a robust and generalizable transcriptomic signature in the blood of PAH patients that can help inform the identification of biomarkers and therapeutic targets.
Collapse
Affiliation(s)
- Jason M Elinoff
- Critical Care Medicine Department, Clinical Center, and National Institutes of Health, Bethesda, Maryland
| | - Adrien J Mazer
- Critical Care Medicine Department, Clinical Center, and National Institutes of Health, Bethesda, Maryland
| | - Rongman Cai
- Critical Care Medicine Department, Clinical Center, and National Institutes of Health, Bethesda, Maryland
| | - Mengyun Lu
- Critical Care Medicine Department, Clinical Center, and National Institutes of Health, Bethesda, Maryland
| | - Grace Graninger
- Critical Care Medicine Department, Clinical Center, and National Institutes of Health, Bethesda, Maryland
| | - Bonnie Harper
- Critical Care Medicine Department, Clinical Center, and National Institutes of Health, Bethesda, Maryland
| | - Gabriela A Ferreyra
- Critical Care Medicine Department, Clinical Center, and National Institutes of Health, Bethesda, Maryland
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, and National Institutes of Health, Bethesda, Maryland
| | - Michael A Solomon
- Critical Care Medicine Department, Clinical Center, and National Institutes of Health, Bethesda, Maryland.,Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, and National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
38
|
Sachdev V, Solomon MA, Masur H. Does HIV Really Augment the Frequency or Mortality Risk of Increased Pulmonary Artery Systolic Pressures? Am J Respir Crit Care Med 2019; 197:854-855. [PMID: 29206065 DOI: 10.1164/rccm.201711-2271ed] [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] [Indexed: 11/16/2022] Open
Affiliation(s)
- Vandana Sachdev
- 1 NHLBI NIH Bethesda, Maryland and.,2 Critical Care Medicine Department NIH Clinical Center Bethesda, Maryland
| | - Michael A Solomon
- 1 NHLBI NIH Bethesda, Maryland and.,2 Critical Care Medicine Department NIH Clinical Center Bethesda, Maryland
| | - Henry Masur
- 1 NHLBI NIH Bethesda, Maryland and.,2 Critical Care Medicine Department NIH Clinical Center Bethesda, Maryland
| |
Collapse
|
39
|
Elinoff JM, Chen LY, Dougherty EJ, Awad KS, Wang S, Biancotto A, Siddiqui AH, Weir NA, Cai R, Sun J, Preston IR, Solomon MA, Danner RL. Spironolactone-induced degradation of the TFIIH core complex XPB subunit suppresses NF-κB and AP-1 signalling. Cardiovasc Res 2019; 114:65-76. [PMID: 29036418 DOI: 10.1093/cvr/cvx198] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 09/26/2017] [Indexed: 02/07/2023] Open
Abstract
Aims Spironolactone (SPL) improves endothelial dysfunction and survival in heart failure. Immune modulation, including poorly understood mineralocorticoid receptor (MR)-independent effects of SPL might contribute to these benefits and possibly be useful in other inflammatory cardiovascular diseases such as pulmonary arterial hypertension. Methods and results Using human embryonic kidney cells (HEK 293) expressing specific nuclear receptors, SPL suppressed NF-κB and AP-1 reporter activity independent of MR and other recognized nuclear receptor partners. NF-κB and AP-1 DNA binding were not affected by SPL and protein synthesis blockade did not interfere with SPL-induced suppression of inflammatory signalling. In contrast, proteasome blockade to inhibit degradation of xeroderma pigmentosum group B complementing protein (XPB), a subunit of the general transcription factor TFIIH, or XPB overexpression both prevented SPL-mediated suppression of inflammation. Similar to HEK 293 cells, a proteasome inhibitor blocked XPB loss and SPL suppression of AP-1 induced target genes in human pulmonary artery endothelial cells (PAECs). Unlike SPL, eplerenone (EPL) did not cause XPB degradation and failed to similarly suppress inflammatory signalling. SPL combined with siRNA XPB knockdown further reduced XPB protein levels and had the greatest effect on PAEC inflammatory gene transcription. Using chromatin-immunoprecipitation, PAEC target gene susceptibility to SPL was associated with low basal RNA polymerase II (RNAPII) occupancy and TNFα-induced RNAPII and XPB recruitment. XP patient-derived fibroblasts carrying an N-terminal but not C-terminal XPB mutations were insensitive to both SPL-mediated XPB degradation and TNFα-induced target gene suppression. Importantly, SPL treatment decreased whole lung XPB protein levels in a monocrotaline rat model of pulmonary hypertension and reduced inflammatory markers in an observational cohort of PAH patients. Conclusion SPL has important anti-inflammatory effects independent of aldosterone and MR, not shared with EPL. Drug-induced, proteasome-dependent XPB degradation may be a useful therapeutic approach in cardiovascular diseases driven by inflammation.
Collapse
Affiliation(s)
| | - Li-Yuan Chen
- Critical Care Medicine Department, Clinical Center
| | | | | | | | | | | | - Nargues A Weir
- Cardiovascular and Pulmonary Branch, National Heart, Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Room 2C145, Bethesda, MD 20892-1662, USA.,Inova Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Fairfax, VA, USA
| | - Rongman Cai
- Critical Care Medicine Department, Clinical Center
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center
| | - Ioana R Preston
- Tupper Research Institute and Pulmonary, Critical Care, and Sleep Division, Tufts Medical Center, Boston, MA 02111, USA
| | - Michael A Solomon
- Critical Care Medicine Department, Clinical Center.,Cardiovascular and Pulmonary Branch, National Heart, Lung and Blood Institute, National Institutes of Health, 10 Center Drive, Room 2C145, Bethesda, MD 20892-1662, USA
| | | |
Collapse
|
40
|
van Diepen S, Fordyce CB, Wegermann ZK, Granger CB, Stebbins A, Morrow DA, Solomon MA, Soble J, Henry TD, Gilchrist IC, Katz JN, Cohen MG, Newby LK. Organizational Structure, Staffing, Resources, and Educational Initiatives in Cardiac Intensive Care Units in the United States: An American Heart Association Acute Cardiac Care Committee and American College of Cardiology Critical Care Cardiology Working Group Cross-Sectional Survey. Circ Cardiovasc Qual Outcomes 2019; 10:e003864. [PMID: 28794122 DOI: 10.1161/circoutcomes.117.003864] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 06/14/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Sean van Diepen
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - Christopher B Fordyce
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - Zachary K Wegermann
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - Christopher B Granger
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - Amanda Stebbins
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - David A Morrow
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - Michael A Solomon
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - Jeffrey Soble
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - Timothy D Henry
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - Ian C Gilchrist
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - Jason N Katz
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - Mauricio G Cohen
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| | - L Kristin Newby
- From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.)
| |
Collapse
|
41
|
Berg DD, Bohula EA, van Diepen S, Katz JN, Alviar CL, Baird-Zars VM, Barnett CF, Barsness GW, Burke JA, Cremer PC, Cruz J, Daniels LB, DeFilippis AP, Haleem A, Hollenberg SM, Horowitz JM, Keller N, Kontos MC, Lawler PR, Menon V, Metkus TS, Ng J, Orgel R, Overgaard CB, Park JG, Phreaner N, Roswell RO, Schulman SP, Jeffrey Snell R, Solomon MA, Ternus B, Tymchak W, Vikram F, Morrow DA. Epidemiology of Shock in Contemporary Cardiac Intensive Care Units. Circ Cardiovasc Qual Outcomes 2019; 12:e005618. [PMID: 30879324 PMCID: PMC11032172 DOI: 10.1161/circoutcomes.119.005618] [Citation(s) in RCA: 200] [Impact Index Per Article: 40.0] [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: 02/17/2019] [Accepted: 02/25/2019] [Indexed: 01/01/2023]
Abstract
Background Clinical investigations of shock in cardiac intensive care units (CICUs) have primarily focused on acute myocardial infarction (AMI) complicated by cardiogenic shock (AMICS). Few studies have evaluated the full spectrum of shock in contemporary CICUs. Methods and Results The Critical Care Cardiology Trials Network is a multicenter network of advanced CICUs in North America. Anytime between September 2017 and September 2018, each center (n=16) contributed a 2-month snap-shot of all consecutive medical admissions to the CICU. Data were submitted to the central coordinating center (TIMI Study Group, Boston, MA). Shock was defined as sustained systolic blood pressure <90 mm Hg with end-organ dysfunction ascribed to the hypotension. Shock type was classified by site investigators as cardiogenic, distributive, hypovolemic, or mixed. Among 3049 CICU admissions, 677 (22%) met clinical criteria for shock. Shock type was varied, with 66% assessed as cardiogenic shock (CS), 7% as distributive, 3% as hypovolemic, 20% as mixed, and 4% as unknown. Among patients with CS (n=450), 30% had AMICS, 18% had ischemic cardiomyopathy without AMI, 28% had nonischemic cardiomyopathy, and 17% had a cardiac cause other than primary myocardial dysfunction. Patients with mixed shock had cardiovascular comorbidities similar to patients with CS. The median CICU stay was 4.0 days (interquartile range [IQR], 2.5-8.1 days) for AMICS, 4.3 days (IQR, 2.1-8.5 days) for CS not related to AMI, and 5.8 days (IQR, 2.9-10.0 days) for mixed shock versus 1.9 days (IQR, 1.0-3.6) for patients without shock ( P<0.01 for each). Median Sequential Organ Failure Assessment scores were higher in patients with mixed shock (10; IQR, 6-13) versus AMICS (8; IQR, 5-11) or CS without AMI (7; IQR, 5-11; each P<0.01). In-hospital mortality rates were 36% (95% CI, 28%-45%), 31% (95% CI, 26%-36%), and 39% (95% CI, 31%-48%) in AMICS, CS without AMI, and mixed shock, respectively. Conclusions The epidemiology of shock in contemporary advanced CICUs is varied, and AMICS now represents less than one-third of all CS. Despite advanced therapies, mortality in CS and mixed shock remains high. Investigation of management strategies and new therapies to treat shock in the CICU should take this epidemiology into account.
Collapse
Affiliation(s)
- 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 (D.D.B, E.A.B., V.M.B.-Z., J.-G.P., D.A.M.)
| | - 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 (D.D.B, E.A.B., V.M.B.-Z., J.-G.P., D.A.M.)
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada (S.v.D., W.T.)
| | - Jason N Katz
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina, Center for Heart and Vascular Care Chapel Hill (J.N.K., R.O.)
| | | | - 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 (D.D.B, E.A.B., V.M.B.-Z., J.-G.P., D.A.M.)
| | | | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (G.W.B., B.T.)
| | - James A Burke
- Lehigh Valley Health Network, Allentown, PA (J.A.B., A.H., F.V.)
| | - Paul C Cremer
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, OH (P.C.C., V.M.)
| | - Jennifer Cruz
- Section of Cardiology, Cooper University Hospital, Camden, NJ (J.C., S.H.)
| | - Lori B Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (L.B.D., N.P.)
| | - Andrew P DeFilippis
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, KY (A.D.)
| | - Affan Haleem
- Lehigh Valley Health Network, Allentown, PA (J.A.B., A.H., F.V.)
| | | | | | - Norma Keller
- New York University Langone Health (J.M.H., N.K., J.N., R.O.R.)
| | | | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, ON, Canada (P.R.L., C.B.O.)
| | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, OH (P.C.C., V.M.)
| | - Thomas S Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (T.S.M., S.P.S.)
| | - Jason Ng
- New York University Langone Health (J.M.H., N.K., J.N., R.O.R.)
| | - Ryan Orgel
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina, Center for Heart and Vascular Care Chapel Hill (J.N.K., R.O.)
| | - Christopher B Overgaard
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, ON, Canada (P.R.L., C.B.O.)
| | - 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, MA (D.D.B, E.A.B., V.M.B.-Z., J.-G.P., D.A.M.)
| | - Nicholas Phreaner
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (L.B.D., N.P.)
| | | | - Steven P Schulman
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (T.S.M., S.P.S.)
| | | | - 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 (M.A.S.)
| | - Bradley Ternus
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (G.W.B., B.T.)
| | - Wayne Tymchak
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada (S.v.D., W.T.)
| | - Fnu Vikram
- Lehigh Valley Health Network, Allentown, PA (J.A.B., A.H., F.V.)
| | - 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 (D.D.B, E.A.B., V.M.B.-Z., J.-G.P., D.A.M.)
| |
Collapse
|
42
|
Brusca SB, Elinoff JM, Jang MK, Demirkale CY, Valantine HA, Solomon MA, Agbor-Enoh S. PLASMA CELL-FREE DNA AS A NOVEL MARKER OF DISEASE SEVERITY IN PULMONARY ARTERIAL HYPERTENSION. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32503-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
43
|
Alviar CL, Miller PE, McAreavey D, Katz JN, Lee B, Moriyama B, Soble J, van Diepen S, Solomon MA, Morrow DA. Positive Pressure Ventilation in the Cardiac Intensive Care Unit. J Am Coll Cardiol 2018; 72:1532-1553. [PMID: 30236315 PMCID: PMC11032173 DOI: 10.1016/j.jacc.2018.06.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [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: 01/18/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 12/16/2022]
Abstract
Contemporary cardiac intensive care units (CICUs) provide care for an aging and increasingly complex patient population. The medical complexity of this population is partly driven by an increased proportion of patients with respiratory failure needing noninvasive or invasive positive pressure ventilation (PPV). PPV often plays an important role in the management of patients with cardiogenic pulmonary edema, cardiogenic shock, or cardiac arrest, and those undergoing mechanical circulatory support. Noninvasive PPV, when appropriately applied to selected patients, may reduce the need for invasive mechanical PPV and improve survival. Invasive PPV can be lifesaving, but has both favorable and unfavorable interactions with left and right ventricular physiology and carries a risk of complications that influence CICU mortality. Effective implementation of PPV requires an understanding of the underlying cardiac and pulmonary pathophysiology. Cardiologists who practice in the CICU should be proficient with the indications, appropriate selection, potential cardiopulmonary interactions, and complications of PPV.
Collapse
Affiliation(s)
- Carlos L Alviar
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - P Elliott Miller
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Dorothea McAreavey
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jason N Katz
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina, Center for Heart and Vascular Care Chapel Hill, Chapel Hill, North Carolina
| | - Burton Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brad Moriyama
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jeffrey Soble
- Division of Cardiovascular Medicine, Rush University Medical Center, Chicago, Illinois
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Michael A Solomon
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
44
|
Elinoff JM, Humbert M, Solomon MA. Reply to Voelkel and Newman: The Light at the End of the Long Pulmonary Hypertension Tunnel Brightens. Am J Respir Crit Care Med 2018; 198:820-821. [PMID: 29944844 DOI: 10.1164/rccm.201804-0792le] [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] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Marc Humbert
- 2 Université Paris-Sud Le Kremlin-Bicêtre, France.,3 Université Paris-Saclay Le Kremlin-Bicêtre, France.,4 INSERM U999 Le Plessis-Robinson, France.,5 Hôpital Bicêtre Le Kremlin-Bicêtre, France and
| | - Michael A Solomon
- 1 NIH Clinical Center Bethesda, Maryland.,6 NHLBI Bethesda, Maryland
| |
Collapse
|
45
|
Elinoff JM, Agarwal R, Barnett CF, Benza RL, Cuttica MJ, Gharib AM, Gray MP, Hassoun PM, Hemnes AR, Humbert M, Kolb TM, Lahm T, Leopold JA, Mathai SC, McLaughlin VV, Preston IR, Rosenzweig EB, Shlobin OA, Steen VD, Zamanian RT, Solomon MA. Challenges in Pulmonary Hypertension: Controversies in Treating the Tip of the Iceberg. A Joint National Institutes of Health Clinical Center and Pulmonary Hypertension Association Symposium Report. Am J Respir Crit Care Med 2018; 198:166-174. [PMID: 29425462 PMCID: PMC6058980 DOI: 10.1164/rccm.201710-2093pp] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 10/23/2017] [Accepted: 02/09/2018] [Indexed: 01/13/2023] Open
Affiliation(s)
| | - Richa Agarwal
- Division of Cardiovascular Disease, Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | | | - Raymond L. Benza
- Division of Cardiovascular Disease, Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Michael J. Cuttica
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ahmed M. Gharib
- National Institute of Diabetes, Digestive, and Kidney Diseases, and
| | | | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marc Humbert
- Service de Pneumologie, Hôpital Bicêtre (Assistance Publique–Hôpitaux de Paris), Institut National de la Santé et de la Recherche Médicale U999, University Paris–Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Todd M. Kolb
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Tim Lahm
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Jane A. Leopold
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Vallerie V. McLaughlin
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ioana R. Preston
- Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | | | - Oksana A. Shlobin
- Pulmonary Vascular Disease Program, Inova Fairfax Hospital, Falls Church, Virginia
| | - Virginia D. Steen
- Rheumatology Division, Department of Medicine, Georgetown University, Washington, DC; and
| | | | | |
Collapse
|
46
|
Suffredini DA, Lee JM, Peer CJ, Pratt D, Kleiner DE, Elinoff JM, Solomon MA. Pulmonary tumor thrombotic microangiopathy and pulmonary veno-occlusive disease in a woman with cervical cancer treated with cediranib and durvalumab. BMC Pulm Med 2018; 18:112. [PMID: 29996818 PMCID: PMC6042377 DOI: 10.1186/s12890-018-0681-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 06/27/2018] [Indexed: 11/16/2022] Open
Abstract
Background Pulmonary tumor thrombotic microangiopathy (PTTM) is a rare cause of pulmonary hypertension that is associated with malignancies and is marked by the presence of non-occlusive tumor emboli and fibrocellular intimal proliferation of small pulmonary arteries leading to increased pulmonary vascular resistance and right heart failure. The diagnosis of PTTM is challenging to make pre-mortem and guidelines on treatment are lacking. Case presentation A 45-year-old woman with advanced squamous cell carcinoma of the cervix developed symptoms of dyspnea and evidence of right heart failure during a phase I clinical trial with cediranib and durvalumab. After an extensive evaluation, pre-capillary pulmonary hypertension was confirmed by right heart catheterization. Vasodilator therapy was initiated but resulted in the development of symptomatic hypoxemia and was discontinued. Despite continued supportive care, she continued to decline and was transitioned to hospice care. At autopsy, the cause of her right heart failure was found to be due to PTTM with features of pulmonary veno-occlusive disease (PVOD). Conclusion PTTM and PVOD are important diagnoses to consider in patients with a malignancy and the development of right heart failure and may be manifestations of a spectrum of similar disease processes.
Collapse
Affiliation(s)
- Dante A Suffredini
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA.
| | - Jung-Min Lee
- Women's Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Cody J Peer
- Clinical Pharmacology Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Drew Pratt
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - David E Kleiner
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Jason M Elinoff
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Michael A Solomon
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA.,Cardiovascular Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, USA
| |
Collapse
|
47
|
Bell TD, Mazer AJ, Miller PE, Strich JR, Sachdev V, Wright ME, Solomon MA. Use of sacubitril/valsartan in acute decompensated heart failure: a case report. ESC Heart Fail 2017; 5:184-188. [PMID: 29035000 PMCID: PMC5793985 DOI: 10.1002/ehf2.12219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 07/19/2017] [Accepted: 08/17/2017] [Indexed: 12/11/2022] Open
Abstract
Refractory heart failure typically requires costly long-term, continuous intravenous inodilator infusions while patients await mechanical circulatory support or cardiac transplantation. The combined angiotensin receptor blocker-neprilysin inhibitor, sacubitril/valsartan, is a novel therapy that can increase levels of endogenous vasoactive peptides. This therapy has been recommended as an alternative agent in patients with chronic heart failure with reduced ejection fraction and New York Heart Association class II-III symptoms. Here, we report a case of a patient with refractory stage D heart failure with reduced ejection fraction who was successfully weaned off continuous intravenous inodilator support using sacubitril/valsartan after prior failed attempts using standard therapies.
Collapse
Affiliation(s)
- Taison D Bell
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,Division of Pulmonary and Critical Care Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Adrien J Mazer
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - P Elliott Miller
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Vandana Sachdev
- Cardiovascular and Pulmonary Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mary E Wright
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Michael A Solomon
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA.,Cardiovascular and Pulmonary Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
48
|
Agbor-Enoh S, Tunc I, De Vlaminck I, Fideli U, Davis A, Cuttin K, Bhatti K, Marishta A, Solomon MA, Jackson A, Graninger G, Harper B, Luikart H, Wylie J, Wang X, Berry G, Marboe C, Khush K, Zhu J, Valantine H. Applying rigor and reproducibility standards to assay donor-derived cell-free DNA as a non-invasive method for detection of acute rejection and graft injury after heart transplantation. J Heart Lung Transplant 2017. [PMID: 28624139 DOI: 10.1016/j.healun.2017.05.026] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [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: 12/12/2022] Open
Abstract
BACKGROUND Use of new genomic techniques in clinical settings requires that such methods are rigorous and reproducible. Previous studies have shown that quantitation of donor-derived cell-free DNA (%ddcfDNA) by unbiased shotgun sequencing is a sensitive, non-invasive marker of acute rejection after heart transplantation. The primary goal of this study was to assess the reproducibility of %ddcfDNA measurements across technical replicates, manual vs automated platforms, and rejection phenotypes in distinct patient cohorts. METHODS After developing and validating the %ddcfDNA assay, we subjected the method to a rigorous test of its reproducibility. We measured %ddcfDNA in technical replicates performed by 2 independent laboratories and verified the reproducibility of %ddcfDNA patterns of 2 rejection phenotypes: acute cellular rejection and antibody-mediated rejection in distinct patient cohorts. RESULTS We observed strong concordance of technical-replicate %ddcfDNA measurements across 2 independent laboratories (slope = 1.02, R2 > 0.99, p < 10-6), as well as across manual and automated platforms (slope = 0.80, R2 = 0.92, p < 0.001). The %ddcfDNA measurements in distinct heart transplant cohorts had similar baselines and error rates. The %ddcfDNA temporal patterns associated with rejection phenotypes were similar in both patient cohorts; however, the quantity of ddcfDNA was significantly higher in samples with severe vs mild histologic rejection grade (2.73% vs 0.14%, respectively; p < 0.001). CONCLUSIONS The %ddcfDNA assay is precise and reproducible across laboratories and in samples from 2 distinct types of heart transplant rejection. These findings pave the way for larger studies to assess the clinical utility of %ddcfDNA as a marker of acute rejection after heart transplantation.
Collapse
Affiliation(s)
- Sean Agbor-Enoh
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland; Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland; Laboratory of Transplantation Genomics, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Ilker Tunc
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Iwijn De Vlaminck
- Department of Bioengineering, Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Ulgen Fideli
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland; Laboratory of Transplantation Genomics, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Andrew Davis
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland; Laboratory of Transplantation Genomics, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Karen Cuttin
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland; Laboratory of Transplantation Genomics, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Kenneth Bhatti
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland; Laboratory of Transplantation Genomics, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Argit Marishta
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland; Laboratory of Transplantation Genomics, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Michael A Solomon
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland; Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Annette Jackson
- Pulmonary and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland; Laboratory of Transplantation Genomics, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Grace Graninger
- Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Bonnie Harper
- Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Helen Luikart
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Wylie
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Xujing Wang
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Gerald Berry
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Charles Marboe
- Department of Medicine, New York Presbyterian University Hospital of Cornell and Columbia, New York, New York
| | - Kiran Khush
- Department of Medicine, New York Presbyterian University Hospital of Cornell and Columbia, New York, New York
| | - Jun Zhu
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Hannah Valantine
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland; Laboratory of Transplantation Genomics, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
| |
Collapse
|
49
|
Awad KS, Elinoff JM, Wang S, Gairhe S, Ferreyra GA, Cai R, Sun J, Solomon MA, Danner RL. Raf/ERK drives the proliferative and invasive phenotype of BMPR2-silenced pulmonary artery endothelial cells. Am J Physiol Lung Cell Mol Physiol 2015; 310:L187-201. [PMID: 26589479 DOI: 10.1152/ajplung.00303.2015] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [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: 08/31/2015] [Accepted: 11/18/2015] [Indexed: 12/21/2022] Open
Abstract
A proliferative endothelial cell phenotype, inflammation, and pulmonary vascular remodeling are prominent features of pulmonary arterial hypertension (PAH). Bone morphogenetic protein type II receptor (BMPR2) loss-of-function is the most common cause of heritable PAH and has been closely linked to the formation of pathological plexiform lesions. Although some BMPR2 mutations leave ligand-dependent responses intact, the disruption of ligand-independent, noncanonical functions are universal among PAH-associated BMPR2 genotypes, but incompletely understood. This study examined the noncanonical signaling consequences of BMPR2 silencing in human pulmonary artery endothelial cells to identify potential therapeutic targets. BMPR2 siRNA silencing resulted in a proliferative, promigratory pulmonary artery endothelial cell phenotype and disruption of cytoskeletal architecture. Expression profiling closely reflected these phenotypic changes. Gene set enrichment and promoter analyses, as well as the differential expression of pathway components identified Ras/Raf/ERK signaling as an important consequence of BMPR2 silencing. Raf family members and ERK1/2 were constitutively activated after BMPR2 knockdown. Two Raf inhibitors, sorafenib and AZ628, and low-dose nintedanib, a triple receptor tyrosine kinase inhibitor upstream from Ras, reversed the abnormal proliferation and hypermotility of BMPR2 deficiency. Inhibition of dysregulated Ras/Raf/ERK signaling may be useful in reversing vascular remodeling in PAH.
Collapse
Affiliation(s)
- Keytam S Awad
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Jason M Elinoff
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Shuibang Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Salina Gairhe
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Gabriela A Ferreyra
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Rongman Cai
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Michael A Solomon
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and Cardiopulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| |
Collapse
|
50
|
Tropea MM, Harper BJA, Graninger GM, Phillips TM, Ferreyra G, Mostowski HS, Danner RL, Suffredini AF, Solomon MA. Isolation of a circulating CD45-, CD34dim cell population and validation of their endothelial phenotype. Thromb Haemost 2014; 112:770-80. [PMID: 25057108 DOI: 10.1160/th14-01-0043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 01/15/2014] [Accepted: 05/14/2014] [Indexed: 11/05/2022]
Abstract
Accurately detecting circulating endothelial cells (CECs) is important since their enumeration has been proposed as a biomarker to measure injury to the vascular endothelium. However, there is no single methodology for determining CECs in blood, making comparison across studies difficult. Many methods for detecting CECs rely on characteristic cell surface markers and cell viability indicators, but lack secondary validation. Here, a CEC population in healthy adult human subjects was identified by flow cytometry as CD45-, CD34dim that is comparable to a previously described CD45-, CD31bright population. In addition, nuclear staining with 7-aminoactinomycin D (7-AAD) was employed as a standard technique to exclude dead cells. Unexpectedly, the CD45-, CD34dim, 7-AAD- CECs lacked surface detectable CD146, a commonly used marker of CECs. Furthermore, light microscopy revealed this cell population to be composed primarily of large cells without a clearly defined nucleus. Nevertheless, immunostains still demonstrated the presence of the lectin Ulex europaeus and von Willebrand factor. Ultramicro analytical immunochemistry assays for the endothelial cell proteins CD31, CD34, CD62E, CD105, CD141, CD144 and vWF indicated these cells possess an endothelial phenotype. However, only a small amount of RNA, which was mostly degraded, could be isolated from these cells. Thus the majority of CECs in healthy individuals as defined by CD45-, CD34dim, and 7-AAD- have shed their CD146 surface marker and are senescent cells without an identifiable nucleus and lacking RNA of sufficient quantity and quality for transcriptomal analysis. This study highlights the importance of secondary validation of CEC identification.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Michael A Solomon
- Michael A. Solomon, MD, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Building 10, Room 2C145, Bethesda, MD 20892-1662, USA, Tel.: +1 301 496 9320, Fax: +1 301 402 1213, E-mail:
| |
Collapse
|