Reduction of Inhospital Mortality of Patient Admissions to Cardiac Intensive Care Units During the COVID-19 Pandemic in Hunan, China.

This study aims to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on patient admissions to Hunan's cardiac intensive care units (CCUs).We conducted a retrospective, single-center study. Data were collected from patients who were confirmed to have critical cardiovascular disease and admitted to the CCU of the Second Xiangya Hospital of Central South University, Hunan, from January 23 to April 23, 2020. Compared with the same period in 2019, the results show that the number of hospitalization decreased by 19.6%; the inhospital mortality rate of CCU was decreased (28.57% versus 16.67%; odds ratio (OR), 0.50; 95% confidence interval (CI), 0.251-0.996; P = 0.047); hospital stay was decreased (7.97 versus 12.36, P < 0.001); hospital emergency percutaneous coronary intervention (PCI) rate in patients with acute coronary syndromes (ACS) significantly decreased (76.00% versus 39.00%, P < 0.001); among this, the PCI rate of patients with ST-segment elevation myocardial infarction (STEMI) decreased (76.32% versus 55.17%, P = 0.028) as well. In addition, the number of patients transferred from other hospitals significantly decreased (76.79% versus 56.67%, P = 0.002), and the number of patients transferred from other cities also decreased by 10.75%.During the outbreak of the COVID-19 epidemic in Hunan Province, the number of patients admitted to CCU decreased, as well as the mortality rate; fewer patients with severe cardiovascular disease can be transported to better hospitals from remote rural areas. In addition to epidemic prevention and control, experts in China should focus on improved emergency transport medical services to reduce this impact.

New challenges in cardiac intensive care units.

Critical care cardiology is a steadily and rapidly developing sub-specialization within cardiovascular medicine, since the first emergence of a coronary care unit in the early 1960s. Today, modern cardiac intensive care units (CICU) serve a complex patient population with a high burden of cardiovascular and non-cardiovascular critical illnesses. Treatment of these patients requires a multidisciplinary approach, with a combination of highly specialized knowledge and skills in cardiovascular diseases, as well as emergency, critical-care and internal medicine. The CICU has always posed special challenges to both experienced intensivists as well as fellows-in-training (FIT) and is certainly one of the most demanding training phases. In recent years, these challenges have grown significantly owing to technological innovations, with new and steadily rising numbers of complex interventional procedures and new options for temporary circulatory support for critically ill patients, such as venoarterial extracorporeal membrane oxygenation (VA-ECMO). Herein, we focus on the successful CICU management of these special patient cohorts, which must become an integral part of critical-care training.

Status of Cardiac Surgical Intensive Care Medicine in Germany in 2018: A Report on Behalf of the German Society for Thoracic and Cardiovascular Surgery.

BACKGROUND: This report summarizes the results of a voluntary survey designed to assess the current situation of cardiac surgical intensive care medicine in Germany in 2018. METHODS: A standardized questionnaire concerning detailed information about structural characteristics of cardiac surgical intensive care units (ICUs) was sent to all German departments performing cardiac surgery. RESULTS: Response rate was 93% (n = 75/81). Compared with previous surveys since 1998, the median number of intensive care beds for patients after cardiac surgery increased from 15 in 2013 to 16 in 2018. The proportion of cardiac surgical ICUs decreased to 51% with a simultaneous increase of interdisciplinary ICUs. The proportion of cardiac surgeons acting as director of an ICU increased to 43%. The physicians' teams were mostly interdisciplinary (57%). More than half of the directors were board-certified intensivists (62%) with a peak of 100% in ICUs run by cardiac surgeons. Human resources development in the ICU showed similar trends with an increase of physicians and nurses. More than half of all ICUs (61%) and the vast majority of cardiac surgical ICUs (82%) offer an accredited training program for intensive care medicine. CONCLUSION: The results of this survey corroborate once again that intensive care medicine represents a substantial and important part of cardiac surgery. However, efforts are necessary to keep this attitude alive for the future.

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.

Impact of a cardiac intensivist on mortality in patients with cardiogenic shock.

BACKGROUND: This study aimed to evaluate the association between high-intensity staffing by a dedicated cardiac intensivist and clinical outcomes in CS. METHODS: We enrolled 2923 consecutive patients admitted to a cardiac care unit (CCU) from January 1, 2012 to December 31, 2015. In January 2013, the CCU changed from a low-intensity to high-intensity staffing unit managed by a dedicated cardiac intensivist. Patients were eligible if they required inotropes or vasopressors to maintain a systolic blood pressure>90mmHg, and had serum lactate≥2.0mmol/L. Eligible patients (n=513) were treated by low-intensity CCU (n=352) or high-intensity CCU (n=161). The primary outcome was CCU mortality. RESULTS: CCU mortality occurred in 49 patients (30.6%) of the low-intensity group versus 62 patients (17.6%) of the high-intensity group (adjusted odds ratio [aOR] 0.44, 95% confidence interval [CI] 0.25-0.75, p<0.001). In-hospital mortality was not significantly different between the groups (33.1% vs 24.4%, aOR 0.75, 95% CI 0.43-1.29, p=0.29). Among 135 patients treated with extracorporeal membrane oxygenation, the high-intensity model was associated with lower CCU mortality (54.5% vs 22.5%, aOR 0.24, 95% CI 0.07-0.77, p=0.02) and in-hospital mortality (57.6% vs 29.4%, aOR 0.28, 95% CI 0.10-0.81, p=0.02). CONCLUSION: High-intensity staffed CCU managed by a dedicated cardiac intensivist was associated with a significant reduction of CS-related mortality.

Description of acute cardiac care in 2014: A French nation-wide database on 277,845 admissions in 270 ICCUs.

BACKGROUND: The Intensive Cardiac Care Unit (ICCU) has greatly evolved for decades: it no longer includes only patients with coronary artery disease (CAD). The clinical characteristics and pathological profiles of patients have markedly changed. Detailed data on the topic are critically lacking. METHODS: We present here a French nation-wide administrative database with an exhaustive description of patients admitted to ICCU throughout a whole year (2014). RESULTS: A total of 277,845 patients in 270 centers were admitted to ICCUs at least once in 2014 (exhaustive data). Median age was 71years (IQR: 59-81) and the patients were primarily male (63%). Mean ICCU stay was 2.0days (1.0-4.0). CAD patients (49.0%) represented the major group admitted, followed by patients with arrhythmias (15.2%) and heart failure (HF) (10.0%). Patients admitted with acute CAD were significantly younger (mean age 67.4 y), had better outcomes (mortality 4.0%), and shorter hospital stays (mean stay 6.7 d). Patients with HF were significantly older (mean age 75.2 y), with longer hospital stays (mean stay 12.0 d), and poorer outcomes (mortality 10.5%). CONCLUSION: We present here the largest contemporary administrative database on patients admitted to ICCUs in a developed country. CAD (mainly acute coronary syndromes) remains the primary cause of admission but the population is, by far, more complex than generally considered.

Phenomenology of delirium among patients admitted to a coronary care unit.

AIM: To study the phenomenology and motor sub-types of delirium in patients admitted in a Coronary Care Unit (CCU). METHODS: Three hundred and nine consecutive patients were screened for delirium, and those found positive for the same were evaluated by a psychiatrist on DSM-IVTR criteria to confirm the diagnosis. Those with a diagnosis of delirium were evaluated on the DRS-R-98 to study the phenomenology and on the amended Delirium Motor Symptom Scale (DMSS) to study the motor sub-types. RESULTS: Eighty-one patients were found to have delirium. Commonly seen symptoms of delirium included: disturbances in sleep-wake cycle, lability of affect, thought abnormality, disturbance in attention, disorientation, short-term memory, and long-term memory. Very few patients had delusions. More than half of the participants were categorized as having hyperactive (n = 46; 56.8%) followed by hypoactive sub-type (n = 21; 26%) and mixed sub-type (n = 9; 11.1%) of delirium. There were minor differences in the frequency and severity of symptoms of delirium between incidence and prevalence cases of delirium and those with different motoric sub-types. CONCLUSION: Delirium in CCU set-up is characterized by the symptoms of disturbances in sleep-wake cycle, lability of affect, thought abnormality, disturbance in attention, disorientation, short-term memory, and long-term memory. Hyperactive delirium is more common than hypoactive delirium.

Longitudinal Changes in ICU Admissions Among Elderly Patients in the United States.

OBJECTIVES: Changes in population demographics and comorbid illness prevalence, improvements in medical care, and shifts in care delivery may be driving changes in the composition of patients admitted to the ICU. We sought to describe the changing demographics, diagnoses, and outcomes of patients admitted to critical care units in the U.S. hospitals. DESIGN: Retrospective cohort study. SETTING: U.S. hospitals. PATIENTS: There were 27.8 million elderly (age, > 64 yr) fee-for-service Medicare beneficiaries hospitalized with an intensive care or coronary care room and board charge from 1996 to 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We aggregated primary International Classification of Diseases, 9th Revision, Clinical Modification discharge diagnosis codes into diagnoses and disease categories. We examined trends in demographics, primary diagnosis, and outcomes among patients with critical care stays. Between 1996 and 2010, we found significant declines in patients with a primary diagnosis of cardiovascular disease, including coronary artery disease (26.6 to 12.6% of admissions) and congestive heart failure (8.5 to 5.4% of admissions). Patients with infectious diseases increased from 8.8% to 17.2% of admissions, and explicitly labeled sepsis moved from the 11th-ranked diagnosis in 1996 to the top-ranked primary discharge diagnosis in 2010. Crude in-hospital mortality rose (11.3 to 12.0%), whereas discharge destinations among survivors shifted, with an increase in discharges to hospice and postacute care facilities. CONCLUSIONS: Primary diagnoses of patients admitted to critical care units have substantially changed over 15 years. Funding agencies, physician accreditation groups, and quality improvement initiatives should ensure that their efforts account for the shifting epidemiology of critical illness.

Innovation in Pediatric Cardiac Intensive Care: An Exponential Convergence Toward Transformation of Care.

The word innovation is derived from the Latin noun innovatus, meaning renewal or change. Although companies such as Google and Apple are nearly synonymous with innovation, virtually all sectors in our current lives are imbued with yearn for innovation. This has led to organizational focus on innovative strategies as well as recruitment of chief innovation officers and teams in a myriad of organizations. At times, however, the word innovation seems like an overused cliché, as there are now more than 5,000 books in print with the word "innovation" in the title. More recently, innovation has garnered significant attention in health care. The future of health care is expected to innovate on a large scale in order to deliver sustained value for an overall transformative care. To date, there are no published reports on the state of the art in innovation in pediatric health care and in particular, pediatric cardiac intensive care. This report will address the issue of innovation in pediatric medicine with relevance to cardiac intensive care and delineate possible future directions and strategies in pediatric cardiac intensive care.

The ten advances that have defined modern cardiology.

Modern cardiology was born early in the twentieth century. Here I list and review what I believe to be the ten most important advances in the twentieth century in this field. They are as follows: electrocardiography, cholesterol-induced atherosclerosis, cardiac catheterization, cardiovascular surgery, coronary angiography and percutaneous coronary angioplasty, the coronary care unit, the development of new cardiovascular drugs, preventive cardiology, cardiac imaging, and implanted cardiac pacemakers/defibrillators.

The organization, function, and outcomes of ST-elevation myocardial infarction networks worldwide: current state, unmet needs and future directions.

The organization of networks in order to better coordinate and to faster offer reperfusion strategies for acute ST-elevation myocardial infarction (STEMI) is an important recommendation of recent versions of international guidelines. This article focusses on similarities and dissimilarities of world-wide networks, highlights essential network components, offers insights into still unmet needs and discusses potential measures to further improve quality of STEMI treatment.

From the coronary care unit to the cardiovascular intensive care unit: the evolution of cardiac critical care.

This article presents an overview of the evolution of cardiac critical care in the past half century. It tracks the rapid advances in the management of cardiovascular disease and how the intensive care area has kept pace, improving outcomes and incorporating successive innovations. The current multidisciplinary, evidence based unit is vastly different from the early days and is expected to evolve further in keeping with the concept of 'hybrid' care areas where care is delivered by the 'heart team'.