Clinical Practice Patterns in Temporary Mechanical Circulatory Support for Shock in the Critical Care Cardiology Trials Network (CCCTN) Registry

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.

Changes in comorbidities, diagnoses, therapies and outcomes in a contemporary cardiac intensive care unit population

Prior studies have demonstrated that the cardiac intensive care unit (CICU) patient population has evolved over time. We sought to describe the temporal changes in comorbidities, illness severity, diagnoses, procedures and adjusted mortality within our CICU practice in recent years.

METHODS

We retrospectively reviewed unique CICU admissions at the Mayo Clinic from January 2007 to April 2018. Comorbidities, severity of illness scores, discharge diagnosis codes and CICU procedures and therapies were recorded, and temporal trends were assessed using linear regression and Cochran-Armitage trend tests. Trends in adjusted hospital mortality over time were assessed using multivariable logistic regression.

RESULTS

We included 12,418 patients with a mean age of 67.6 years (including 37.7% females). Temporal trends in the prevalence of several comorbidities and discharge diagnoses were observed, reflecting an increase in the prevalence of non-coronary cardiovascular diseases, critical care diagnoses, and organ failure (all P ≪ .05). The use of several CICU therapies and procedures increased over time, including mechanical ventilation, invasive lines and vasoactive drugs (all P ≪ .05). A temporal decrease in adjusted hospital mortality was observed among the subgroup of patients with (adjusted OR per year 0.97, 95% CI 0.94-0.99, P = .023) and without (adjusted OR per year 0.91, 95% CI 0.85-0.96, P = .002) a critical care discharge diagnosis.

CONCLUSIONS

We observed an increasing prevalence of critical care and organ failure diagnoses as well as increased utilization of critical care therapies in this CICU cohort, associated with a decrease in risk-adjusted hospital mortality over time.

The impact of progress toward a Clinical Development Unit in Cardiology

Health care organisations are continually implementing quality initiatives to develop staff to enhance the provision of patient care. However, the impact of such initiatives often fail to be assessed which can jeopardise provision for their systematic support. This paper reviews staff perceptions of how progress toward a Clinical Development Unit has influenced their practice in Cardiology. The process began in August 2003 when the unit philosophy included the use of best evidence into practice. Key initiatives integral to the development of a CDU were: facilitated engagement with clinical evidence, assisted through a structured education program for all staff; and opportunities for involvement in patient centred research. This evaluation sought descriptive information from staff as sustainability of such units is reliant on positive attitudes. Feedback was obtained from a convenience sample of staff who participated in three focus groups conducted over two months, 29 staff in total. Prevailing themes that emerged indicated the development of a positive ward culture. Four dominant themes emerged: the development of a culture of evidence into practice; a continuous learning environment; awareness of the contribution of research; and a re-focus on patient care. While structures and processes were in place to support learning and practices based in evidence that staff viewed favourably, there was little indication of individual staff members being 'pro-active' and being initiators of seeking evidence to make changes to practice.

Cardiac centres of excellence. 'Royal Brompton': the specialist centre in London that specialist centres consult

It may be diagnosing Thalassaemia with magnetic resonance, navigating catheters round tight corners with magnets, or treating Marfan's syndrome with the Brompton Sheath--but if it is state of the art and it works, the Royal Brompton & Harefield NHS Foundation Trust, London, will almost certainly have pioneered it, reports Barry Shurlock MA, PhD.

Increasing cardiac interventions among the aged

Ireland's over 65 year population is growing. As incidence of coronary events rises with age, there is a growing population of elderly patients with cardiac disease. The changing age profile of patients treated by a tertiary hospital's Cardiology service was quantified using Hospital Inpatient Enquiry data. 53% of CCU admissions were aged > or = 65 years, with admissions aged > or = 85 years in 2008 four times greater than in 2002. Percentages of patients undergoing diagnostic coronary angiography and percutaneous coronary interventions in 1997 aged > or = 70 years were 19% and 18% respectively. By 2007, these percentages had risen to 31% and 34% respectively--greatest increases were in the very elderly age categories. The proportion of ICD recipients aged > 70 years increased from 8% in 2003 to 25% by 2008. The proportion of elderly patients receiving advanced cardiac care is increasing. This trend will continue and has clear resource implications. Outcomes of interventions in the very old need further investigation, since the 'old old' are under-represented in clinical trials.

Epidemiology of acute myocardial infarction with the emphasis on patients who did not reach the coronary care unit and non-AMI admissions

OBJECTIVES

To describe the characteristics and outcome of patients with acute myocardial infarction (AMI) in a community, with particular emphasis on those who never reached a Coronary Care Unit (CCU) and those in whom the primary diagnosis was something other than a heart attack.

METHODS

Patients hospitalised in the city of Göteborg, Sweden, and discharged (dead or alive) with a diagnosis of AMI.

RESULTS

Among 1423 patient admissions the mean overall age was 75 years (81 years and 79 years in the two subsets). Among all patients, 33% had a history of heart failure and 20% had a history of cerebrovascular disease. The figures were even higher in the two subsets which were evaluated. In overall terms, an invasive strategy (coronary angiography) was used in 32% (in 5% and 9% in the two subsets respectively). The overall one-year and three-year mortality rate was 30% and 44% respectively. The three-year mortality rate among patients not admitted to a CCU was 65% and, among patients with no suspicion of a heart attack on admission, it was 68%.

CONCLUSION

Even in the 21st century, patients with AMI who reach hospital alive run a high risk of death and nearly half are dead within the first three years. In overall terms, patients are characterised by high age and high co-morbidity. Among patients who do not reach a CCU and among patients with no suspicion of AMI on admission, approximately two thirds are dead within the subsequent three years.

[Coronary care units: who to admit and how long]

Coronary care units (CCUs) should ensure the best intensive therapy for all critical cardiologic patients and not only for patients with acute coronary heart disease. Such structures apply the Hub & Spoke model, which consists of an integrated network of services allowing a health organization in which different realities interact and collaborate; this organization is composed of referral core centers (Hubs) and smaller structures (Spokes) referring to Hubs that are engaged in selection, channeling of patients in the acute phase, and for follow-up care of patients in the post-acute phase. The CCUs, based on the organizational reality in which they operate, must hospitalize and dismiss complex patients in a brief lapse of time. Criteria for CCU admission and length of stay are still ill-defined. Therefore, the following paper, summarizing the contents of the recent CCU convention at the ANMCO congress, attempts to define the priorities for hospitalization in the CCU, based on three different levels of evidence: level A indication (immediate mandatory admission); level B indication (immediate admission, the availability of beds allowing); level C indication (admission not indicated, but possible in the absence of other alternatives, e.g. limited bed availability in other intensive care units). Concerning the duration of stay within the CCU, clear-cut indications are difficult, but the concept is emphasized that the length of stay should be minimized, given the limited bed availability, in order to ensure the availability of intensive monitoring to all critical patients.

The recent evolution of coronary care units into intensive cardiac care units: the experience of a tertiary center in Florence

OBJECTIVES

To evaluate the evolution of intensive cardiac care units (ICCUs) in the third millenium by assessing the activity and the workload of our ICCU which is a Hub center, from 1 January 2004 to 30 June 2005.

METHODS

Among the 1397 patients consecutively admitted to our ICCU, 40.5% came from Spokes. Patients with ST elevation myocardial infarction comprised 29.5% of the entire population: all of them were admitted to ICCU after mechanical reperfusion.

RESULTS

The incidences of ventricular fibrillation (1%) and complete AV block (0.6%) are low in our patients. The most frequent complications were acute renal failure requiring renal replacement therapy (4.4%) and vascular and hemorrhagic complications (4.3%).

CONCLUSIONS

Our ICCU is a post-reperfusion unit for treating complications of therapy and older and more complex patients who require more intensive care. This is why the cardiac intensivists also need to be skilled in general intensive care. In the Integrated Cardiac Network (Hub-and-Spoke model), ICCUs play a crucial role in the management of all cardiac emergencies, and in maintaining a continuous and strict interplay with Spokes, they have a prominent and unique role in the selection and early treatment of acute cardiac patients and their follow-up.

Cardiology and the Critical Care Crisis

With an aging U.S. population and a declining physician supply, the care of critically ill patients will soon be reaching a level of crisis. At the same time, the evidence continues to mount in support of intensivist staffing to improve both patient outcomes and resource utilization in intensive care units (ICUs). Whereas the vast majority of medical and surgical ICUs are staffed by physicians trained in critical care medicine, that is not commonly the case in coronary care units (CCUs) in this country. Despite that, the breadth and diversity of comorbidities in patients that occupy our CCU beds is continuously growing. No longer is the CCU merely an observation unit for peri-infarction complications, but rather it has truly become an ICU for patients with cardiovascular disease. With this in mind, there becomes a growing need for intensivist-trained cardiologists and a push for the development of critical care training pathways in our cardiovascular fellowship programs.

Patients with acute myocardial infarction have an inaccurate understanding of their risk of a future cardiac event

BACKGROUND

Accurate perceptions of future cardiac risk are important to ensure informed treatment choices and lifestyle adaptation in patients following myocardial infarction (MI). The aim of this study was to investigate whether risk perceptions of patients with MI were accurate compared with an established clinical risk model.

METHODS

Seventy-nine consecutive patients with acute MI admitted to the Coronary Care Unit, Auckland Hospital, completed a questionnaire assessing risk perceptions. Clinical data were used to calculate patients' Thrombolysis In Myocardial Infarction (TIMI) risk scores, a validated predictive model of prognosis. The main outcome measures were the associations between perceived risk, TIMI risk scores and troponin T.

RESULTS

Patients' risk perceptions showed no correlation with thrombolysis in myocardial infarction risk scores (r = -0.06; P = 0.61) or with troponin T (r = -0.07; P = 0.53). Patients' risk perceptions were not significantly associated with age or sex, and were not significantly higher in those who had experienced a previous MI, a family history of coronary heart disease, diabetes or smokers. Higher perceived risk was significantly associated with a number of illness perceptions, including worse consequences of the MI and lower beliefs in the benefit of treatment. Patients who overestimated their risk were more anxious than other patients (F(2, 73) = 22.97; P = 0.0001).

CONCLUSION

Patients with MI ideas about their personal risk of future MI are not congruent with their clinical risk assessments. Inpatient hospital care appears to be unsuccessful in communicating prognosis effectively to patients. Improving the accuracy of risk perceptions may help decrease unnecessary cardiac anxiety and invalidism in some patients and prompt risk-reducing behaviours in others.

[Future perspectives of cardiovascular intensive care medicine]

The future perspectives of cardiovascular intensive care medicine (CVICM) are affected by an ever increasing number of elderly (> 65 years), old (> 75 years) and very old (> 85 years) patients with the incidental clinical consequences, by an increase in inpatient days due to the increasing number of patients who have to be treated despite cost pressure, and by the attempts to integrate CVICM into one interdisciplinary intensive care unit (ICU) including medical and surgical patients, although proof of equal or even superior outcome, process or structural quality is lacking presently. To overcome all the problems mentioned, CVICM must develop from a mainly consensus-oriented to a more evidence-oriented medicine; CVICM must find ways to improve the poorly validated hemodynamic monitoring concept by pulmonary artery catheter and look for additional, less invasive monitoring techniques and better monitoring parameters; CVICM must support the search for new and hopefully better pharmacotherapeutic agents and cardiovascular assist devices as presently available to support the failing heart and the impaired vascular system; and CVICM must also learn to control noncardiac processes like inflammation and multi-organ failure, which often are responsible for the fatal outcome of the ICU patient with cardiovascular disease. Real challenges for the cardiovascular intensivist are refractory shock and refractory septic cardiomyopathy, these cardiovascular disease entities being responsible for every other fatality in the wake of severe sepsis and septic shock. To handle these tremendous challenges of CVICM, training of the young cardiologists in CVICM must be intensified, and much more attention to cardiovascular topics and techniques must be paid when training our colleagues in medical intensive care medicine.

Fourteen-year (1987 to 2000) trends in the attack rates of, therapy for, and mortality from non-ST-elevation acute coronary syndromes in four United States communities

During the past 2 decades, randomized trials have proved the efficacy of several treatments for non-ST-elevation acute coronary syndromes (NSTE-ACSs), including aspirin, beta blockers, and coronary revascularization. However, the cumulative effectiveness of these evolving therapies in actual clinical practice remains unknown. The Atherosclerosis Risk In Communities (ARIC) surveillance study uses rigorous prospective community surveillance to monitor the epidemiology of coronary heart disease among subjects who are 35 to 74 years of age and reside in 4 United States communities, with a population totaling 370,000 subjects. We identified 6,379 ARIC surveillance patients who were hospitalized with NSTE-ACS (defined as cardiac chest pain and ST depression or T-wave inversion on the presenting electrocardiogram) between 1987 and 2000 and then analyzed 30-day and 1-year mortalities by calendar year of admission. Using logistic regression, 30-day mortality was modeled first using predictor variables of the calendar year, ARIC community, and indicators of severity and co-morbidity and then by adding variables for treatment with aspirin, beta blockers, and coronary revascularization to this model. Crude 30-day mortality decreased from 8.6% in 1988 to 3.6% in 2000 (p for trend <0.001), a trend that remained significant (p = 0.006) after adjustment for case severity and co-morbidity. The trend became nonsignificant after adjustment for treatment variables, suggesting that newer treatments may explain the improved survival. In conclusion, 30-day mortality from NSTE-ACS has decreased as treatment has improved.

Critical pathways in the emergency department improve treatment modalities for patients with ST-elevation myocardial infarction in a European hospital

BACKGROUND

The use of protocols for patients with ST-elevation myocardial infarction (MI) is growing, but no definite conclusion regarding the value of critical pathways in Europe has been drawn.

HYPOTHESIS

The aim of this study was to investigate the impact of critical pathway on processes of care and outcome for patients presenting to the emergency department (ED) of a large urban European hospital because of possible ST-elevation MI.

METHODS

Critical pathways for management of acute chest pain at our ED were developed in 1998 and have been revised every year. Accordingly, the records of all patients referred in 1997 to the ED because of chest pain (before pathway implementation) and in 2001 (after last pathway revision) were reviewed. An ST-elevation MI was diagnosed at ED in 520 of 5,066 (10.3%) patients with chest pain in 1997, and in 452 of 4,843 (9.3%) patients with chest pain in 2001. Patients were managed according to the ED cardiologists' decisions in 1997, whereas they entered the pathways for ST-elevation MI in 2001, with predefined criteria for diagnosis, thrombolysis, percutaneous coronary intervention, and admission to the coronary care unit.

RESULTS

Comparison of treatment modalities disclosed that more patients were given thrombolysis in 1997 (49 vs. 16%, p<0.05), whereas in 2001 more patients were sent to primary angioplasty (63 vs. 11%, p<0.05). Also in 2001, patients more often received aspirin (90 vs. 61%, p<0.05) and intravenous beta blockers (60 vs. 35%, p<0.05) soon after arrival at the ED. Comparison between 1997 and 2001 revealed that admission rates to the coronary care unit (69 vs. 78%, NS) and cardiac wards were similar (19 vs. 10%, NS). Conversely, compared with 1997, patients hospitalized in 2001 had a shorter length of stay (12 +/- 5 vs. 18 +/- 6 days, p<0.05), as well as fewer major adverse coronary events (21 vs. 30%, p<0.05) and lower all-cause in-hospital mortality (12 vs. 20%, p<0.05). The quality of care indicators improved with time, as door-to-electrocardiogram interval (10 +/- 6 vs. 19 +/- 9 min, p<0.05), door-to-needle time (25 +/- 10 vs. 35 +/- 10 min, p<0.05), and door-to-balloon interval (70 +/- 15 vs. 99 +/- 20 min, p<0.05) were shorter in 2001 than in 1997.

CONCLUSIONS

A critical pathway for ST-elevation MI at the ED increases the use of evidence-based treatment strategies and improves outcome and quality of care of patients presenting to a European hospital because of acute chest pain.

Taking the "critical" out of critical cardiac care: what does the future hold for cardiac care units?

This article identifies the rapid advancement of invasive and noninvasive interventional cardiac technologies. The newest cardiac diagnostics are those awaiting Food and Drug Administration approval will have a significant impact in relation to the acuity of future critically ill cardiac patients. While the elderly population continues to grow, these recipients of healthcare will also have more education available to them and hopefully will be practicing healthier lifestyles. There are several research studies in process that will change the future of critical care patients as well as critical care nurses. This article identifies approaches to the treatments and management of coronary artery disease, heart failure, and cardiac arrhythmias as they impact coronary heart disease, which still remains the leading cause of death in the United States.

Coronary care medicine: it's not your father's CCU anymore

The management of ST-elevation MI (STEMI) has gone through four phases: 1. The "clinical observation phase"; 2. the "coronary care unit phase"; 3. the "high-technology phase"; and 4. the "evidence-based coronary care phase". A significant advance in the care of patients with acute myocardial infarction that arose as an outgrowth of the evidence-based era was introduction of a lexicon that more accurately reflected contemporary concepts of the pathophysiology underlying myocardial ischemia and infarction. Although considerable improvement has occurred in the process of care for patient with STEMI, room for improvement exists. Despite strong evidence in the literature that prompt use of reperfusion therapy improves survival of STEMI patients such treatment is underutilized and often not administered in an expeditious timeframe relative to the onset of symptom. Even in the reperfusion era, left ventricular dysfunction remains the single most important predictor of mortality following STEMI. After administration of aspirin, initiating reperfusion strategies and, where appropriate, beta blockade all STEMI patients should be considered for inhibition of the renin-angiotensin-aldosterone system. Several adjunctive pharmacotherapies have been investigated to prevent inflammatory damage in the infarct zone. Contrary to earlier beliefs that the heart is a terminally differentiated organ without the capacity to regenerate, evidence now exists that human cardiac myocytes divide after STEMI and stem cells can promote regeneration of cardiac tissue. These observations open up the possibility of myocardial replacement therapy after STEMI.

Structuring cardiology services for the 21st century

Segregating patients into small coronary care units began in the 1960s. This step was deemed necessary for two reasons: (1) the high mortality and often profound morbidity of patients who had acute myocardial infarction and (2) the boom in treatment technologies, with the introduction of bedside oscilloscopes, defibrillation, and mechanical and pharmacological means of resuscitation and pacing. Another series of technology booms in cardiology has occurred in the 1990s. This new technology and other associated factors may signal the need for reviewing the cardiac care environment. This article presents the evolution of acute care in cardiology from the 1960s to 1996 and questions the continuing need for small, highly staffed cardiac care units. In the current climate of technological refinements, improved nursing education, and a large and diverse population of cardiovascular patients, these units may be redundant.

Evolution of the CCU from rhythm, function and protection to reperfusion and beyond: a personal journey and perspective

OBJECTIVE

To trace the evolution of coronary care and the management of acute coronary syndromes.

STUDY SELECTION

Landmark articles and selected personal experiences.

DATA SYNTHESIS

The evolution of coronary care falls into four major categories and decades: the 1960s during which it was recognized that resuscitation from myocardial infarction through closed chest resuscitation (CPR) and defibrillation were possible and attention was directed towards the recognition and management of cardiac dysrhythmias; in the 1970s it became appreciated that infarct size was directly related to prognosis and modifiable. Hemodynamic monitoring was introduced and made significant contributions to the identification of prognostic subsets and the pharmacologic management of pump failure; thrombolytic therapy was introduced in the 1980s and has markedly altered the care of patients with acute myocardial infarction who have ST elevation. Primary angioplasty is an important therapeutic alternative especially in selected subsets; in the 1990s attention shifted to opportunities for favourable impact on ventricular remodelling after myocardial infarction, more cost effective therapy, enhancement of the process of care, and the identification of low and high risk subsets that might lead to more efficient diagnostic triage early after symptom presentation.

CONCLUSIONS

There has been a profound evolution of the coronary care unit since its inception in Canada in 1962. It has proved a remarkable environment for education and clinical investigation through which patient care has been substantially improved. Lessons learned have favourably impacted on the process of care, the creation of new national and international standards and a fertile environment for continuous future evaluation and improvement.

Mortality trends in the coronary care unit

To evaluate the clinical features, complication rates, and mortality from infarction in the coronary care unit, we analysed all cases of acute myocardial infarction admitted to the Coronary Care Unit of the Singapore General Hospital over a 4 month period in 1988. There were 184 cases of acute infarction with a male:female ratio of 3.4:1. Fifty-five percent of patients were aged 60 years or above. Complications included congestive cardiac failure in 40%, sustained ventricular tachycardia in 9%, cardiogenic shock in 18% and complete heart block in 8%. The overall in-hospital mortality was 20.6%. Multiple logistic regression analysis of clinical variables showed that of the clinical variables, age (elderly patients) and the diabetes were independently associated with a higher mortality as well as development of cardiogenic shock and sustained ventricular tachycardia. Comparing our results with previous smaller studies of CCU outcome in 1975 and 1967, there was a marked increase in the proportion of elderly patients in 1988 but despite this the overall mortality rate was not significantly different. Age is the most important clinical variable predicting outcome from infarction.

The changing face of twentieth-century American cardiology

The meaning of American cardiology has been transformed over the past century. During that time, cardiology has been defined by several organizations: by the American Board of Internal Medicine through subspecialty certifications; by the two major American cardiology societies, the American Heart Association and the American College of Cardiology; and by the four major cardiology journals. These organizations have sometimes cooperated, sometimes competed. Cardiology has also had to negotiate relationships with several external interest groups, including pediatrics, surgery, hospitals, and internal medicine. Throughout the 20th century, the word cardiology has had no meaning save its definition within a larger web of organizations, relationships, and ideas. The meaning, like the meaning of all specialties and subspecialties, is historically mediated and constantly changing.