Oral aspirin or low dose of intravenous lysine acetylsalicylate in ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

AIM: To compare the pharmacodynamic effect of an oral loading dose of 'noncoated' ASA 300 mg vs. an intravenous bolus injection of lysine acetylsalicylate 150 mg in patients with STEMI undergoing pPCI. METHODS: This was a prospective single-center, open label, pharmacodynamic study, including nonconsecutive patients presenting at our catheterization laboratory with STEMI undergoing pPCI and not receiving ASA within the previous 7 days. Pharmacodynamic analyses were performed at five time points: baseline, and 1, 2, 4 and 12 h after the loading dose, and measured as ASA reaction units (ARU) by the Verify Now System. An ARU more than 550 was considered as nonresponsiveness to study drugs. The primary end point was the different rate of patients with ARU more than 550 at 2 h after the loading dose of oral vs. intravenous ASA. Secondary end points included the comparison of ARU more than 550 at the other time points and the comparison of continuous ARU at each time point. RESULTS: The study was planned with a sample size of 68 patients, but it was prematurely stopped due to slow enrollment after the inclusion of 23 patients, 12 randomized to oral ASA and 11 to intravenous lysine acetylsalicylate. At 2 h the rate of patients with ARU more than 550 was numerically but not significantly higher in patients receiving oral ASA as compared with intravenous lysine acetylsalicylate (33 vs. 14.2%; Δ -0.19, 95% confidence interval -0.59-0.21, P = 0.58). The difference over time was NS (P = 0.98), though the prevalence of ARU more than 550 was higher at the other time points. Both routes of administration reduced ARU values over time, though with no overall significant difference between profiles (P overall = 0.48). CONCLUSION: In patients with STEMI undergoing pPCI the rate of nonresponsiveness to ASA was not different comparing an oral 'noncoated' loading dose of ASA with an intravenous bolus injection of lysine acetylsalicylate. However, as patient enrollment was prematurely terminated, this study is underpowered to draw a definite conclusion.

Predictors of complications in initially haemodynamically stable patients admitted in a modern coronary care unit.

AIMS: Resource optimization in the intensive cardiac care unit (ICCU) is, nowadays, of great importance because of the increasing number of acute cardiovascular patients requiring high-intensity level-of-care. Because of natural limits in ICCU bed availability, understanding, which patients will really benefit from in a such a critical care setting, is of paramount importance. In our study, we analysed a heterogeneous ICCU population with initially stable haemodynamic conditions, in order to find potential predictors of severe complications. METHODS: Nine hundred and fifty patients admitted to our ICCU during the year 2019 were screened in order to detect those with a stable haemodynamic condition at admission. Data were extrapolated from an internal database. Comorbidity burden was expressed by the Charlson Comorbidity Index (CCI). Our primary end point was defined by a combination of severe complications requiring critical care, and in-hospital death. RESULTS: Ninety-eight patients (14.1% of 695 stable patients identified) developed severe complications. After a multivariable logistic regression analysis, four predictors were identified: signs of congestive heart failure [OR: 9.25, 95% confidence interval (CI): 5.61-15.25; P < 0.001], SBP 120 mmHg or less (OR: 2.10, 95% CI: 1.27-3.47; P = 0.004), haemoglobin level 13 g/dl or less (OR: 1.75, 95% CI: 1.03-2.95; P = 0.037), and the CCI above 3 (OR: 2.27, 95% CI: 1.13-4.56; P = 0.022). CONCLUSION: In our study, 73% of patients showed a stable haemodynamic condition on admission. Severe complications occurred in 14.1% of these patients, and signs of heart failure were the main determinants of the outcome. SBP, haemoglobin level, and the CCI concurred in the prediction of severe complications during the hospital stay.

Surge-in-Place: Conversion of a Cardiac Catheterization Laboratory Into a COVID-19 Intensive Care Unit and Back Again.

In Spring 2020, the United States epicenter of COVID-19 was New York City, in which the borough of the Bronx was particularly affected. This Fall, there has been a resurgence of COVID-19 in Europe and the Midwestern United States. We describe our experience transforming our cardiac catheterization laboratories to accommodate an influx of COVID-19 patients so as to provide other hospitals with a potential blueprint. We transformed our pre/postprocedural patient care areas into COVID-19 intensive care and step-down units and maintained emergent invasive care for ST-segment elevation myocardial infarction using existing space and personnel.

Early Mobilization in People With Acute Cardiovascular Disease.

BACKGROUND: Early mobilization (EM) is recommended in critical care units. However, there is little known about EM in people with acute cardiovascular disease. METHODS: Consecutive admissions to a tertiary-care cardiovascular intensive care unit (CICU) before and after implementation of an EM program were reviewed. The Level of Function (LOF) Mobility Scale, which ranges from 0 (bed immobile) to 5 (able to walk >20 m), was used to measure and guide mobility. The primary outcome was discharge home. RESULTS: There were 1489 patients included in the analysis (preintervention, N = 637; intervention, N = 852). There were no differences in age, sex, or admission for ischemic heart disease (age 68.1 ± 16.1 years; 39.3% female). In the intervention cohort, one-quarter (N = 222; 26.1%) had at least mildly impaired prehospital functional status. The LOF was 4.6 ± 0.7 prehospital, 3.2 ± 1.4 on admission, and 4.2 ± 0.9 on CICU discharge. Half of patients (51.6%) increased their LOF by ≥1 during CICU admission. Nearly all mobility opportunities had a mobility activity (97.0%). The adverse event rate was 0.3% with no life-threatening events, falls, line dislodgements, or health care personnel injuries. The intervention group, compared with the preintervention group, was more likely to be discharged home (83.9% vs 78.3%, P < 0.007) and had a lower rate of in-hospital death (4.2% vs 6.8%; P = 0.04). When adjusted for age, sex, and comorbid illness, admission LOF was a predictor of discharge to health care facility (odds ratio = 0.72; P < 0.001). CONCLUSIONS: EM is safe and feasible in the CICU and effective at increasing discharge home.

Prevention of Complications in the Cardiac Intensive Care Unit: A Scientific Statement From the American Heart Association.

Contemporary cardiac intensive care units (CICUs) have an increasing prevalence of noncardiovascular comorbidities and multisystem organ dysfunction. However, little guidance exists to support the development of best-practice principles specific to the CICU. This scientific statement evaluates strategies to avoid the potentially preventable complications encountered within contemporary CICUs, focusing on those that are most applicable to the CICU environment. This scientific statement reviews evidence-based practices derived in non-CICU populations, assesses their relevance to CICU practice, and highlights key knowledge gaps warranting further investigation to attenuate patient risk.

Elaboração de projeto pedagógico para preceptoria de enfermeiros em terapia intensiva cardiológica / Elaboration of a pedagogical project for preceptory nurses in intensive cardiological therapy / Elaboración de un proyecto pedagógico para enfermeras preceptorias en terapia cardiológica intensiva

Objetivo: relatar a elaboração de um projeto pedagógico em preceptoria para enfermeiros em terapia intensiva cardiológica. Método: estudo descritivo, exploratório, com abordagem qualitativa, do tipo relato de experiência, realizado em um Hospital Universitário Federal. Relato baseado na experiência de enfermeiras preceptoras em residência multiprofissional na área de concentração Enfermagem e atuantes na terapia intensiva cardiológica durante o ano de 2019. Resultados: a elaboração de um planejamento pedagógico para preceptoria de enfermeiros em terapia intensiva cardiológica contribui para sistematizar as atividades de estágio do residente, aprimorando o binômio teoria e prática, favorecendo assim, que os enfermeiros desenvolvam no exercício de sua profissão, atitudes reflexivas, críticas, humanitárias e éticas, com responsabilidade e competência para atuar em terapia intensiva cardiológica. Conclusão: por meio desse projeto pedagógico de estágio proporcionamos a melhoria da educação e formação dos residentes no âmbito da terapia intensiva cardiológica, bem como fomentamos a educação permanente e constante atualização.(AU)

Objective: to report the development of a pedagogical project in preceptorship for nurses in cardiac intensive care. Method: a descriptive, exploratory study with a qualitative approach, of the experience report type, carried out in a Federal University Hospital. Report based on the experience of preceptor nurses in multidisciplinary residency in the area of concentration Nursing and working in cardiac intensive care during 2019. Results: the elaboration of a pedagogical planning for preceptorship of nurses in cardiac intensive care contributes to systematize the internship activities of the resident, improving the binomial theory and practice, thus favoring that nurses develop reflexive, critical, humanitarian and ethical attitudes in the exercise of their profession, with responsibility and competence to work in cardiac intensive therapy. Conclusion: through this pedagogical internship project we provide the improvement of education and training of residents in the scope of cardiac intensive care, as well as promoting permanent education and constant updating.(AU)

Objetivo: informar la elaboración de un proyecto pedagógico en preceptoría para enfermeras en cuidados intensivos cardíacos. Método: estudio exploratorio descriptivo con enfoque cualitativo, del tipo de informe de experiencia, realizado en un Hospital de la Universidad Federal. Informe basado en la experiencia de las enfermeras preceptoras en residencia multiprofesional en el área de concentración Enfermería y activa en cuidados intensivos cardíacos durante 2019. Resultados: la elaboración de una planificación pedagógica para la preceptación de enfermeras en cuidados intensivos cardíacos contribuye a sistematizar las actividades de pasantía del residente, mejorando la teoría y la práctica binomial, favoreciendo así que las enfermeras desarrollen actitudes reflexivas, críticas, humanitarias y éticas en el ejercicio de su profesión, con responsabilidad y competencia para trabajar en terapia intensiva cardíaca. Conclusión: a través de este proyecto de pasantía pedagógica, brindamos la mejora de la educación y la capacitación de los residentes en el ámbito de la atención intensiva cardíaca, así como promovemos la educación permanente y la actualización constante.(AU)

Anion Gap Was Associated with Inhospital Mortality and Adverse Clinical Outcomes of Coronary Care Unit Patients.

BACKGROUND: Anion gap (AG) has been proved to be associated with prognosis of many cardiovascular diseases. This study is aimed at exploring the association of AG with inhospital all-cause mortality and adverse clinical outcomes in coronary care unit (CCU) patients. METHOD: All data of this study was extracted from Medical Information Mart for Intensive Care III (MIMIC-III, version 1.4) database. All patients were divided into four groups according to AG quartiles. Primary outcome was inhospital all-cause mortality. Lowess smoothing curve was drawn to describe the overall trend of inhospital mortality. Binary logistic regression analysis was performed to determine the independent effect of AG on inhospital mortality. RESULT: A total of 3593 patients were enrolled in this study. In unadjusted model, as AG quartiles increased, inhospital mortality increased significantly, OR increased stepwise from quartile 2 (OR, 95% CI: 1.01, 0.74-1.38, P = 0.958) to quartile 4 (OR, 95% CI: 2.72, 2.08-3.55, P < 0.001). After adjusting for possible confounding variables, this association was attenuated, but still remained statistically significant (quartile 1 vs. quartile 4: OR, 95% CI: 1.02, 0.72-1.45 vs. 1.49, 1.07-2.09, P = 0.019). Moreover, CCU mortality (P < 0.001) and rate of acute kidney injury (P < 0.001) were proved to be higher in the highest AG quartiles. Length of CCU (P < 0.001) and hospital stay (P < 0.001) prolonged significantly in higher AG quartiles. Maximum sequential organ failure assessment score (SOFA) (P < 0.001) and simplified acute physiology score II (SAPSII) (P < 0.001) increased significantly as AG quartiles increased. Moderate predictive ability of AG on inhospital (AUC: 0.6291), CCU mortality (AUC: 0.6355), and acute kidney injury (AUC: 0.6096) was confirmed. The interactions were proved to be significant in hypercholesterolemia, congestive heart failure, chronic lung disease, respiratory failure, oral anticoagulants, Beta-blocks, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), and vasopressin treatment subgroups. CONCLUSION: AG was an independent risk factor of inhospital all-cause mortality and was associated with adverse clinical outcomes in CCU patients.

Association Between Hospital Cardiac Catheter Laboratory Status, Use of an Invasive Strategy, and Outcomes After NSTEMI.

BACKGROUND: Increased use of invasive coronary strategies in patients admitted to hospitals with on-site cardiac catheter laboratory (CCL) facilities has been reported, but the utilisation of invasive coronary strategies according to types of CCL facilities at the first admitting hospital and clinical outcomes is unknown. METHODS: We included 452,216 patients admitted with a diagnosis of non-ST-segment-elevation myocardial infarction (NSTEMI) in England and Wales from 2007 to 2015. The admitting hospitals were categorized into no-laboratory, diagnostic, and PCI hospitals according to CCL facilities. Multilevel logistic regression models were used to study associations between CCL facilities and in-hospital outcomes. RESULTS: A total of 97,777 (21.6%) of the patients were admitted to no-laboratory hospitals, and 134,381 (29.7%) and 220,058 (48.7%) were admitted to diagnostic and PCI hospitals, respectively. Use of coronary angiography was significantly higher in PCI hospitals (77.3%) than in diagnostic (63.2%) and no-laboratory (61.4%) hospitals. The adjusted odds of in-hospital mortality were similar for diagnostic (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.83-1.04) and PCI hospitals (OR 1.09, 95% CI 0.96-1.24) compared with no-laboratory hospitals. However, in high-risk NSTEMI subgroup (defined as Global Registry of Acute Coronary Events score > 140), an admission to diagnostic hospitals was associated with significantly increased in-hospital mortality (OR 1.36, 95% CI 1.06-1.75) compared with no-laboratory and PCI hospitals. CONCLUSIONS: This study highlights important differences in both the utilisation of invasive coronary strategies and subsequent management and outcomes of NSTEMI patients according to admitting hospital CCL facilities. High-risk NSTEMI patients admitted to diagnostic hospitals had greater in-hospital mortality, possibly because of reduced PCI use, which needs to be addressed.

Factores predictivos de complicaciones intrahospitalarias en el Síndrome Coronario Agudo sin elevación del segmento ST / Predictive factors of intra-hospital complications in Non-ST-segment elevation Acute Coronary Syndrome

Introducción: El espectro clínico de los Síndromes Coronarios Agudos sin elevación del segmento ST incluye tanto a pacientes asintomáticos como a los que presentan isquemia activa, inestabilidad eléctrica, hemodinámica o parada cardiaca. Objetivo: Evaluar probables factores predictivos de complicaciones intrahospitalarias no letales en pacientes con diagnóstico de Síndrome Coronario Agudo sin elevación del segmento ST. Material y Métodos: Estudio observacional, analítico, de corte transversal con un universo de 218 individuos ingresados en la Unidad de Cuidados Coronarios Intensivos del Hospital Clínico-Quirúrgico Manuel Fajardo en 2016 y 2017. Resultados: Predominó el sexo masculino (51.4 por ciento) y la edad media fue de 68 años. Prevaleció la Hipertensión Arterial como factor de riesgo coronario. La edad mostró asociación estadística significativa con la aparición de cualquier complicación (p=0.015) y con las complicaciones hemodinámicas (p=0,014). El riesgo intermedio-alto, según el score TIMI, tuvo asociación estadísticamente muy significativa con las complicaciones hemodinámicas (p<0.01). Conclusiones: La edad tuvo asociación estadística con la aparición de complicaciones intrahospitalarias no letales. El sexo no se asoció con las complicaciones ni los antecedentes estudiados tampoco. Los pacientes con un riesgo intermedio-alto al ingreso, se asociaron con las complicaciones hemodinámicas(AU)

Introduction: The clinical spectrum of Non-ST-segment elevation Acute Coronary Syndromes includes both asymptomatic patients and those with active ischemia, electrical instability, hemodynamic or cardiac arrest. Objective: To evaluate probable predictive factors of non-lethal intra-hospital complications in patients diagnosed with Non-ST-segment elevation Acute Coronary Syndrome. Material and Methods: An observational, analytical, cross-sectional study was conducted with a universe of 218 individuals admitted into the Intensive Coronary Care Unit of Manuel Fajardo Clinical and Surgical Hospital between 2016 and 2017. Results: Male sex predominated (51.4 percent) and the mean age was 68 years. Arterial Hypertension prevailed as a coronary risk factor. The age showed significant statistical association with the appearance of any complication (p = 0.015) and with hemodynamic complications (p =0,014). The intermediate-high risk, according to the TIMI score, had a statistically significant association with hemodynamic complications (p <0.01). Conclusions: Age was statistically associated with the appearance of non-lethal intra-hospital complications. Sex was not associated with complications, nor did the background studied either. Patients with an intermediate-high risk at admission were associated with hemodynamic complications(AU)

Caracterización de fallecidos por Infarto de Miocardio en una Unidad de Cuidados Coronarios Intensivos / Characterization of patients who died after a Myocardial Infarction in an Intensive Coronary Care Unit

Introducción: Las enfermedades cardiovasculares constituyen un serio problema de salud a nivel mundial, la cardiopatía isquémica representa gran parte de este problema del cual Cuba no está exenta. Objetivo: Caracterizar a los pacientes fallecidos por infarto agudo de miocardio en la Unidad de cuidados coronarios intensivos del Hospital clínico-quirúrgico Comandante Manuel Fajardo en el período comprendido entre junio 2009 a marzo 2017. Material y Métodos: Estudio observacional, descriptivo, de corte transversal con un universo de 50 pacientes fallecidos por infarto agudo de miocardio. Resultados: Edad media de 62,6 años ± 7. Predominó el infarto de localización anterior (76 por ciento), unido a los pacientes con Killip-Kimball III - IV y con TIMI de riesgo bajo con un (68 por ciento) y (40 por ciento) respectivamente. El 56 por ciento del universo no recibió terapia de reperfusión y el shock cardiogénico (40 por ciento) fue constatado como complicación más presentada. Conclusiones: Predominaron los pacientes con infarto de cara anterior y los de clasificación de Killip-Kimbal III-IV, sin asociación estadísticamente significativa entre ambas variables. También fueron mayoría los no trombolizados y los que presentaron shock cardiogénico como complicación, aunque estas variables tampoco mostraron asociación estadísticamente significativa(AU)

Introduction: Cardiovascular diseases are a serious health problem worldwide. Ischemic Cardiopathy represents a high percentage of this problem, and Cuba is not excluded. Objective: To characterize patients who died after Acute Myocardial Infarction in the Intensive Coronary Care Unit of the Clinical-Surgical Hospital Comandante Manuel Fajardo in the period from June 2009 to March 2017. Material and Methods: Observational, descriptive, cross-sectional study with a universe of 50 patients who died of acute myocardial infarction. Results: The mean age was 62.6 ± 7 years. The anterior myocardial infarction predominated (76 percent), together with patients classified according to Killip-Kimball III-IV criteria that also had low TIMI risk (68 percent and a 40 percent, respectively). 56 percent of the universe of patients was not thrombosed, and cardiogenic shock (40 percent) was confirmed as the most common complication. Conclusions: Patients with anterior myocardial infarction and Killip-Kimbal III-IV classification predominated in the study, without statistically significant association between these two variables. Most patients were not thrombosed and they were the ones who presented cardiogenic shock as a complication, although these variables also showed no statistically significant association(AU)

The effect of nature sounds on physiological indicators among patients in the cardiac care unit.

BACKGROUND AND OBJECTIVES: Environmental noises may create physiological and psychological disorders in patients hospitalized in the CCU. Therefore, this study was conducted to investigate the effects of nature sounds on physiological indicators among patients in the CCU. MATERIALS & METHODS: This randomized clinical trial was conducted on 93 patients hospitalized in the cardiac care units of three teaching hospitals in 2016. The patients were selected using the convenient method with three randomized blocks. The patients were assigned into three groups as nature sounds, silence that received a set of headphones without playing sounds, and control groups. In addition to routine care, the patients in the intervention group listened to nature sounds for 30 min using a set of headphones for two days. The patients in the control group only received routine care. In addition to routine care, the patients in the silence group used a set of headphones for 30 min to block noises and no sound was played for them. Physiological indicators such as heartbeat rate, systolic and diastolic blood pressures, respiration rate, and arterial O2 saturation were assessed using monitoring devices. Descriptive and inferential statistics were used for data analysis via the SPSS software. FINDINGS: Nature sounds and silence had no statistically significant effects on physiological indicators. However, a statistically significant difference was reported in the heart rate in the nature sound group before and after the intervention in the first day of the intervention (P = 0.046). In the second day of the intervention, there were statistically significant differences in the diastolic blood pressure in the nature sounds group (P = 0.028), heart rate (P = 0.001) and diastolic blood pressure (P = 0.013) in the silence group, and heart rate (P = 0.014) in the control group before and after the intervention. CONCLUSION: Listening to nature sounds or the use of headphones blocked environmental noises and could influence mean arterial pressure. Future studies can examine the effects of this intervention implemented for a longer term using nature sounds by patients.

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.

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.

Do stable non-ST-segment elevation acute coronary syndromes require admission to coronary care units?

BACKGROUND: Clinical practice guidelines recommend admitting patients with stable non-ST-segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two-thirds of patients are admitted to higher-acuity critical care units (CCUs). The outcomes of patients with stable NSTE ACS initially admitted to a CCU vs a cardiology ward with telemetry have not been described. METHODS: We used population-based data of 7,869 patients hospitalized with NSTE ACS admitted to hospitals in Alberta, Canada, between April 1, 2007, and March 31, 2013. We compared outcomes among patients initially admitted to a CCU (n=5,141) with those admitted to cardiology telemetry wards (n=2,728). RESULTS: Patients admitted to cardiology telemetry wards were older (median 69 vs 65years, P<.001) and more likely to be female (37.2% vs 32.1%, P<.001) and have a prior myocardial infarction (14.3% vs 11.5%, P<.001) compared with patients admitted to a CCU. Patients admitted directly to cardiology telemetry wards had similar hospital stays (6.2 vs 5.7days, P=.29) and fewer cardiac procedures (40.3% vs 48.5%, P<.001) compared with patients initially admitted to CCUs. There were no differences in the frequency of in-hospital mortality (1.3% vs 1.2%, adjusted odds ratio [aOR] 1.57, 95% CI 0.98-2.52), cardiac arrest (0.7% vs 0.9%, aOR 1.37, 95% CI 0.94-2.00), 30-day all-cause mortality (1.6% vs 1.5%, aOR 1.50, 95% CI 0.82-2.75), or 30-day all-cause postdischarge readmission (10.6% vs 10.8%, aOR 1.07, 95% CI 0.90-1.28) between cardiology telemetry ward and CCU patients. Results were similar across low-, intermediate-, and high-risk Duke Jeopardy Scores, and in patients with non-ST-segment myocardial infarction or unstable angina. CONCLUSIONS: There were no differences in clinical outcomes observed between patients with NSTE ACS initially admitted to a ward or a CCU. These findings suggest that stable NSTE ACS may be managed appropriately on telemetry wards and presents an opportunity to reduce hospital costs and critical care capacity strain.

[Telecardiology: clinical, technical and social aspects. The project of the ASP of Cosenza, Italy]. / Telecardiologia: aspetti clinici, tecnici e sociali. Il progetto dell'ASP di Cosenza.

The aim of this paper is to present the project of telecardiology within the ASP of Cosenza, one of the largest provinces of Italy characterized by a particular orography, with difficult and inaccessible roads. The goal of this project is to manage the emergency more efficiently by reducing the time of intervention by bringing the patient not to the nearest hospital, but more importantly to the hospital more appropriately suited to better manage the cardiological emergency. This system also uses the most modern web-based interface technology protected by login and password. The project also provides the integration, supply and installation of advanced and modern central by ensuring efficient screening is carried out using monitors in all the coronary care units of the ASP of Cosenza, networking with electrocardiography of all the point of first medical contact and all the 118 emergency rescue service. By integrating all these procedures and information and making them available to any point in the hospital and territorial network, this project becomes not only a more efficient system for managing cardiac emergency but also a pathway that will guarantee increased care of patients from the onset of symptoms to discharge.

Vasoactive Drugs and Hemodynamic Monitoring in Pediatric Cardiac Intensive Care: An Italian Survey.

BACKGROUND: Little is known about practitioner preference, the availability of technology, and variability in practice with respect to hemodynamic monitoring and vasoactive drug use after congenital heart surgery. The aim of this study was to characterize current hospital practices related to the management of low cardiac output syndrome (LCOS) across Italy. METHODS: We issued a 22-item questionnaire to 14 Italian hospitals performing pediatric cardiac surgery. RESULTS: Electrocardiogram, invasive blood pressure, central venous pressure, pulse oximetry, diuresis, body temperature, arterial lactate, and blood gas analysis were identified as routine in hemodynamic monitoring. With regard to advanced hemodynamic monitoring, pulmonary arterial catheter and transpulmonary thermodilution were available in 43% of the centers, uncalibrated pulse contour methods in 29% of the centers, and transesophageal/transthoracic echocardiograms in all of the centers. Dopamine added to milrinone was the most frequent drug regimen for LCOS prevention after cardiopulmonary bypass. Overall, 86% of centers used milrinone alone as the initial treatment for LCOS with elevated systemic vascular resistances and levosimendan, the second preferred choice. In cases of LCOS with low vascular resistance, epinephrine was the first choice (10 centers), dopamine was the second choice (4 centers), followed by vasopressin and norepinephrine (3 centers). For treatment of LCOS with elevated pulmonary resistances, milrinone was the first choice (eight centers), followed by inhaled nitric oxide (five centers). CONCLUSIONS: The survey shows that advanced hemodynamic monitoring is rarely performed. The most commonly used vasoactive drugs are milrinone, levosimendan, dopamine, epinephrine, vasopressin, and norepinephrine. Guidelines on the topic are warranted.

Effectiveness, safety and feasibility of an evidence-based insulin infusion protocol targeting moderate glycaemic control in intensive cardiac care units.

OBJECTIVES: To assess the effectiveness, safety and feasibility of the revised, simplified nurse-managed version of our insulin infusion protocol, adapted to the new recommended glycaemic target of 140 to 180 mg/dL (Desio Diabetes Diagram i.v. 140-180). METHODS: All clinical responses to the Desio Diabetes Diagram i.v. 140-180 in use for 3 years were recorded in patients with diabetes or hyperglycaemia admitted to our intensive cardiac care unit. To assess the feasibility, we asked nurses to complete an ad hoc questionnaire anonymously when the new insulin infusion protocol had been in use for 2 years. RESULTS: From December 2010 to December 2013, 276 patients (173 men, median age 75 years) were treated according to the Desio Diabetes Diagram i.v. 140-180. The median time to reach glycaemic target was 4 h (Q1-Q3 2-8) in 128 patients with blood glucose >180 mg/dL and 2 h (Q1-Q3 1-4) in 82 patients with blood glucose <140 mg/dL. Once the target had been reached, insulin infusion was maintained for a median of 38 h (Q1-Q3 24-48) with blood glucose between 140 and 180 mg/dL for 58.3% of the infusion time. Over a total of 11,863 h of infusion, seven blood glucose <70 mg/dL occurred. The Desio Diabetes Diagram i.v. 140-180 protocol was considered easy to use by 93% of nurses. CONCLUSIONS: The Desio Diabetes Diagram i.v. 140-180 protocol, fully managed by nurses, with insulin and glucose intravenous infusion proved effective, safe and feasible in maintaining blood glucose between 140 and 180 mg/dL in patients with diabetes or hyperglycaemia admitted to the intensive cardiac care unit for acute cardiac events.

Hospital variation in admission to intensive care units for patients with acute myocardial infarction.

BACKGROUND: The treatment for patients with acute myocardial infarction (AMI) was transformed by the introduction of intensive care units (ICUs), yet we know little about how contemporary hospitals use this resource-intensive setting and whether higher use is associated with better outcomes. METHODS: We identified 114,136 adult hospitalizations for AMI from 307 hospitals in the 2009 to 2010 Premier database using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. Hospitals were stratified into quartiles by rates of ICU admission for AMI patients. Across quartiles, we examined in-hospital risk-standardized mortality rates and usage rates of critical care therapies for these patients. RESULTS: Rates of ICU admission for AMI patients varied markedly among hospitals (median 48%, Q1-Q4 20%-71%, range 0%-98%), and there was no association with in-hospital risk-standardized mortality rates (6% all quartiles, P = .7). However, hospitals admitting more AMI patients to the ICU were more likely to use critical care therapies overall (mechanical ventilation [from Q1 with lowest rate of ICU use to Q4 with highest rate 13%-16%], vasopressors/inotropes [17%-21%], intra-aortic balloon pumps [4%-7%], and pulmonary artery catheters [4%-5%]; P for trend < .05 in all comparisons). CONCLUSIONS: Rates of ICU admission for patients with AMI vary substantially across hospitals and were not associated with differences in mortality, but were associated with greater use of critical care therapies. These findings suggest uncertainty about the appropriate use of this resource-intensive setting and a need to optimize ICU triage for patients who will truly benefit.