'Weekend Effect' in Acute Pulmonary Embolism Management and Outcomes.

None.

Utilization of inpatient palliative care services in cardiac arrest complicating acute pulmonary embolism.

Introduction: The role of palliative care services in patients with cardiac arrest complicating acute pulmonary embolism has been infrequently studied. Methods: All adult admissions with pulmonary embolism complicating cardiac arrest were identified using the National Inpatient Sample (2016-2020). The primary outcome of interest was the utilization of palliative care services. Secondary outcomes included predictors of palliative care utilization and its association of with in-hospital mortality, do-not-resuscitate status, discharge disposition, length of stay, and total hospital charges. Multivariable regression analysis was used to adjust for confounding. Results: Between 01/01/2016 and 12/31/2020, of the 7,320 admissions with pulmonary embolism complicating cardiac arrest, 1229 (16.8 %) received palliative care services. Admissions receiving palliative care were on average older (68.1 ± 0.9 vs. 63.2 ± 0.4 years) and with higher baseline comorbidity (Elixhauser index 6.3 ± 0.1 vs 5.6 ± 0.6) (all p < 0.001). Additionally, this cohort had higher rates of non-cardiac organ failure (respiratory, renal, hepatic, and neurological) and invasive mechanical ventilation (all p < 0.05). Catheter-directed therapy was used less frequently in the cohort receiving palliative care, (2.8 % vs 7.9 %; p < 0.001) whereas the rates of systemic thrombolysis, mechanical and surgical thrombectomy were comparable. The cohort receiving palliative care services had higher in-hospital mortality (85.7 % vs. 69.1 %; adjusted odds ratio 2.20 [95 % CI 1.41-3.42]; p < 0.001). This cohort also had higher rates of do-not-resuscitate status and fewer discharges to home, but comparable hospitalization costs and length of hospital stay. Conclusions: Palliative care services are used in only 16.8 % of admissions with cardiac arrest complicating pulmonary embolism with significant differences in the populations, suggestive of selective consultation.

Race, Ethnicity, and Gender Disparities in Acute Myocardial Infarction.

Cardiovascular disease continues to be the leading cause of morbidity and mortality in the United States. Despite advancements in medical care, there remain persistent racial, ethnic, and gender disparity in the diagnosis, treatment, and prognosis of individuals with cardiovascular disease. In this review we seek to discuss differences in pathophysiology, clinical course, and risk profiles in the management and outcomes of acute myocardial infarction and related high-risk states. We also seek to highlight the demographic and psychosocial inequities that cause disparities in acute cardiovascular care.

Short-term and long-term outcomes of cardiac arrhythmias in patients with cardiogenic shock.

INTRODUCTION: Cardiogenic shock is severe circulatory failure that results in significant in-hospital mortality, related morbidity, and economic burden. Patients with cardiogenic shock are at high risk for atrial and ventricular arrhythmias, particularly within the subset of patients with an overlap of cardiogenic shock and cardiac arrest. AREAS COVERED: This review article will explore the prevalence, definition, management, and outcomes of common arrhythmias in patients with cardiogenic shock. This review will describe the pathophysiology of arrhythmia in cardiogenic shock and the impact of inotropic agents on increased arrhythmogenicity. In addition to medical management, focused assessment of mechanical circulatory support, radiofrequency ablation, deep sedation, and stellate ganglion block will be provided. EXPERT OPINION: We will navigate the limited data and describe the prognostic impacts of arrhythmia. Finally, we will conclude the review with a discussion of prevention strategies, research limitations, and future research directions.

Palliative care in the cardiovascular intensive care unit: A systematic review of current literature.

BACKGROUND: There has been an evolution in the disease severity and complexity of patients presenting to the cardiac intensive care unit (CICU). There are limited data evaluating the role of palliative care in contemporary CICU practice. METHODS: PubMed Central, CINAHL, EMBASE, Medline, Cochrane Library, Scopus, and Web of Science databases were evaluated for studies on palliative care in adults (≥18 years) admitted with acute cardiovascular conditions - acute myocardial infarction, cardiogenic shock, cardiac arrest, advanced heart failure, post-cardiac surgery, spontaneous coronary artery dissection, Takotsubo cardiomyopathy, and pulmonary embolism - admitted to the CICU, coronary care unit or cardiovascular intensive care unit from 1/1/2000 to 8/8/2022. The primary outcome of interest was the utilization of palliative care services. Secondary outcomes of included studies were also addressed. Meta-analysis was not performed due to heterogeneity. RESULTS: Of 5711 citations, 30 studies were included. All studies were published in the last seven years and 90 % originated in the United States. Twenty-seven studies (90 %) were retrospective analyses, with a majority from the National Inpatient Sample database. Heart failure was the most frequent diagnosis (47 %), and in-hospital mortality was reported in 67 % of studies. There was heterogeneity in the timing, frequency, and background of the care team that determined palliative care consultation. In two randomized trials, there appeared to be improvement in quality of life without an impact on mortality. CONCLUSIONS: Despite the growing recognition of the role of palliative care, there are limited data on palliative care consultation in the CICU.

Training Paradigms in Critical Care Cardiology: A Scoping Review of Current Literature.

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.

Prevalence of respiratory failure and use of mechanical ventilation in heart failure patients undergoing left atrial appendage occlusion device implantation.

BACKGROUND: We sought to evaluate respiratory complications in heart failure patients undergoing left atrial appendage occlusion (LAAO) for stroke prevention in atrial fibrillation. METHODS: Adult admissions (>18 years) undergoing LAAO during 2016-2020 were identified from the National Inpatient Sample. Heart failure (HF) was stratified into systolic (SHF) and diastolic heart failure (DHF) and were compared to those without HF. Outcomes of interested included acute respiratory failure, use of non-invasive and invasive mechanical ventilation, and in-hospital mortality. RESULTS: Of 74,440 admissions for atrial fibrillation undergoing LAAO, SHF and DHF were noted in 8335 (11.2%) and 10,925 (14.7%), respectively. The SHF cohort was predominantly male (78%) whereas DHF cohort were female (53%). Compared to those without HF, presence of SHF (2.3% vs. 0.6%; adjusted odds ratio [OR] 1.61 [95% confidence interval {CI} 1.10-2.36]; p = 0.01) and DHF (2.8% vs. 0.6%; adjusted OR 2.20 [95% CI 1.58-3.06]; p < 0.001) were associated with higher rates of acute respiratory failure. SHF (1.7% vs. 0.6%; adjusted OR 1.70 [95% CI 1.07-2.71]; p = 0.02) group but not DHF (1.2% vs. 0.6%; adjusted OR 1.21 [95% CI 0.78-1.89]; p = 0.39) was associated with higher rates of non-invasive ventilation, whereas the DHF group (0.9% vs. 0.2%; adjusted OR 1.91 [95% CI 1.08-3.34]; p = 0.02) but not SHF (0.8% vs. 0.2%; adjusted OR 1.54 [95% CI 0.83-2.84]; p = 0.17) was associated with higher rates of invasive mechanical ventilation use. In-hospital mortality was comparable between cohorts. CONCLUSION: Compared to those without HF, atrial fibrillation admissions with HF undergoing LAAO had higher rates of acute respiratory failure and mechanical ventilation rates without differences in in-hospital mortality.

Comparative Outcomes of Catheter-Directed Thrombolysis Plus Systemic Anticoagulation Versus Systemic Anticoagulation Alone in the Management of Intermediate-Risk Pulmonary Embolism in a Systematic Review and Meta-Analysis.

There are limited and conflicting data on the initial management of intermediate-risk (or submassive) pulmonary embolism (PE). This study sought to compare the outcomes of catheter-directed thrombolysis (CDT) in combination with systemic anticoagulation (SA) to SA alone. A systematic search was conducted in MEDLINE, EMBASE, PubMed, and the Cochrane databases from inception to March 1, 2023 for studies comparing the outcomes of CDT + SA versus SA alone in intermediate-risk PE. The outcomes were in-hospital, 30-day, 90-day, and 1-year mortality; bleeding; blood transfusion; right ventricular recovery; and length of stay. Random-effects models was used to calculate the pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs). A total of 15 (2 randomized and 13 observational) studies with 10,549 (2,310 CDT + SA and 8,239 SA alone) patients were included. Compared with SA, CDT + SA was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.001), 30-day mortality (RR 0.34, 95% CI 0.18 to 0.67, p = 0.002), 90-day mortality (RR 0.34, 95% CI 0.17 to 0.67, p = 0.002), and 1-year mortality (RR 0.58, 95% CI 0.34 to 0.97, p = 0.04). There were no significant differences between the 2 cohorts in the rates of major bleeding (RR 1.39, 95% CI 0.72 to 2.68, p = 0.56), minor bleeding (RR 1.83, 95% CI 0.97 to 3.46, p = 0.06), and blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08). In conclusion, CDT + SA is associated with significantly lower short-term and long-term all-cause mortality, without any differences in major/minor bleeding, in patients with intermediate-risk PE.

Myocarditis post-COVID-19 vaccination.

There has been much interest in the possible adverse events associated with available anti-coronavirus disease of 2019 (COVID-19) vaccines, given the rapid pace at which they had to be developed during the pandemic. One such adverse event is myocarditis post-COVID-19 vaccination. Several pathophysiological mechanisms have been proposed that might help us understand the relationship between the messenger ribonucleic acid (mRNA) vaccine and the occurrence of myocarditis, though we are yet to ascertain the causal link between them. Although the actual absolute incidence of myocarditis post-COVID-19 vaccination remains low among the large, general population that has been vaccinated, there has been a high relative incidence of this adverse event. We aim to review the existing literature and bring to light what we have so far understood with respect to the association between COVID-19 vaccination and myocarditis. This will help in better understanding the burden of the pathology along with alleviating apprehensions associated with it.

Constrictive Pericarditis: A Diagnostic Conundrum.

A 65-year-old male presented with chest pain, tachycardia, tachypnea, and diminished breath sounds. His lab investigations revealed an elevated leukocyte count, erythrocyte sedimentation rate, and B-type natriuretic peptide. Transthoracic echocardiography and chest imaging revealed the presence of pericardial effusion without tamponade and he was treated for presumed acute idiopathic pericarditis. He was started on indomethacin and colchicine but he stopped them prematurely due to side effects. Subsequently, he developed pleural effusions and ascites requiring multiple thoracenteses and paracenteses. Due to equivocal echocardiographic findings, he underwent invasive hemodynamic measurements which demonstrated equalization of filling pressures and ventricular interdependence, confirming constrictive pericarditis. Due to ongoing pericardial inflammation on cardiovascular magnetic resonance imaging, he was treated with a prednisone taper. Due to persistent symptoms and fibrosis of the pericardium on cross-section imaging, he underwent pericardiectomy. He did well with the procedure and has had an uneventful clinical follow-up.

Anti-N-methyl-D-aspartate receptor encephalitis in pregnancy associated with teratoma.

A 36-year-old pregnant woman with a prior history of depression and recent gunshot wounds presented with sudden deterioration in her mental status. Clinical examination revealed psychosis, hallucinations, and lack of orientation, with an otherwise normal neurological and cardiorespiratory examination. Computed tomographic scan of her head was normal, and she was diagnosed with acute psychosis and excited delirium. She did not respond to supraphysiologic dosages of antipsychotic therapy and needed physical restraints for combativeness and agitation. Her cerebrospinal fluid analysis was negative for an infectious etiology, but was positive for anti-N-methyl-D-aspartate receptor encephalitis antibodies. Abdominal imaging revealed a right-sided ovarian cyst. Subsequently she underwent right-sided oophorectomy. Postoperatively the patient continued to have intermittent episodes of agitation requiring antipsychotic medications. Later, she was safely transitioned to home care with family support.

RIGHT VENTRICULAR DYSFUNCTION IN SEPSIS: AN UPDATED NARRATIVE REVIEW.

ABSTRACT: Sepsis is a multisystem disease process, which constitutes a significant public health challenge and is associated with high morbidity and mortality. Among other systems, sepsis is known to affect the cardiovascular system, which may manifest as myocardial injury, arrhythmias, refractory shock, and/or septic cardiomyopathy. Septic cardiomyopathy is defined as the reversible systolic and/or diastolic dysfunction of one or both ventricles. Left ventricle dysfunction has been extensively studied in the past, and its prognostic role in patients with sepsis is well documented. However, there is relatively scarce literature on right ventricle (RV) dysfunction and its role. Given the importance of timely detection of septic cardiomyopathy and its bearing on prognosis of patients, the role of RV dysfunction has come into renewed focus. Hence, through this review, we sought to describe the pathophysiology of RV dysfunction in sepsis and what have we learnt so far about its multifactorial nature. We also elucidate the roles of different biomarkers for its detection and prognosis, along with appropriate management of such patient population.

Efficacy and safety of angiotensin II in cardiogenic shock: A systematic review.

BACKGROUND: Cardiogenic shock (CS) is associated with high morbidity and mortality. In recent times, there is increasing interest in the role of angiotensin II in CS. We sought to systematically review the current literature on the use of angiotensin II in CS. METHODS: PubMed, EMBASE, Medline, Web of Science, PubMed Central, and CINAHL databases were systematically searched for studies that evaluated the efficacy of angiotensin II in patients with CS during 01/01/2010-07/07/2022. Outcomes of interest included change in mean arterial pressure (MAP), vasoactive medication requirements (percent change in norepinephrine equivalent [NEE] dose), all-cause mortality, and adverse events. RESULTS: Of the total 2,402 search results, 15 studies comprising 195 patients were included of which 156 (80%) received angiotensin II. Eleven patients (84.6%) in case reports and case series with reported MAP data at hour 12 noted an increase in MAP. Two studies noted a positive hemodynamic response (defined a priori) in eight (88.9%) and five (35.7%) patients. Eight studies reported a reduction in NEE dose at hour 12 after angiotensin II administration and one study noted a 100% reduction in NEE dose. Out of 47 patients with documented information, 13 patients had adverse outcomes which included hepatic injury (2), digital ischemia (1), ischemic optic neuropathy (1), ischemic colitis (2), agitated delirium (1), and thrombotic events (2). CONCLUSIONS: In this first systematic review of angiotensin II in CS, we note the early clinical experience. Angiotensin II was associated with improvements in MAP, decrease in vasopressor requirements, and minimal reported adverse events.

Correlation of oxidative stress with vitamin D and glycated hemoglobin in patients with type 2 diabetes mellitus.

Type 2 diabetes mellitus (T2DM) has a heavy disease burden and is one of the leading causes of death worldwide. It is considered to be evolving from a complex and multifactorial metabolic disorder to an inflammatory condition. The strong link between hyperglycemia and oxidative stress has long been established. Oxidative stress leads to the generation of inflammatory mediators and reactive oxygen species, which results in an inflammatory state, which plays a key role in the pathogenesis of diabetic complications. Vitamin D is also known to affect insulin sensitivity. We aimed to correlate the levels of glycated hemoglobin (HbA1c) and vitamin D with oxidative stress. This cross-sectional study included 100 patients with T2DM. Oxidative stress was estimated by lipid peroxidation assay for activity of malondialdehyde (MDA), as well as superoxide dismutase (SOD) levels. HbA1c was estimated using ion-exchange chromatography. Vitamin D was estimated using enzyme-linked immunosorbent assay. The data were analyzed using a t test. The results showed that as the duration of T2DM increased, the levels of SOD and MDA also increased. No significant correlation was found between SOD and MDA with HbA1c (P = 0.995 and 0.195) and vitamin D (P = 0.874 and 0.051), respectively.

Society of Cardiovascular Angiography and intervention Stage-B cardiogenic shock: An interventional-heart failure-critical care conundrum.

The Society of Cardiovascular Angiography and Intervention (SCAI) classified cardiogenic shock (CS) into five stages ranging from A-E. There remains significant ambiguity regarding the assessment and management of SCAI Stage B. Given its nebulous nature that can rapidly escalate, prompt interventions are needed. Here, we describe the trajectory of cases that presented with SCAI Stage B CS.

Valve-in-valve transcatheter mitral valve replacement procedure in prosthetic valve stenosis.

A patient presented with acute respiratory failure and shock due to severe prosthetic mitral valve stenosis. A valve-in-valve transcatheter mitral valve replacement procedure was performed via the transeptal approach due to his high-risk presentation with good results.

In COVID-19 acute hypoxemic respiratory failure, awake prone positioning vs. the supine position reduces intubations.

SOURCE CITATION: Li J, Luo J, Pavlov I, et al. Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: a systematic review and meta-analysis. Lancet Respir Med. 2022;10:573-83. 35305308.