Personalized prescription of ACEI/ARBs for hypertensive COVID-19 patients.

The COVID-19 pandemic has prompted an international effort to develop and repurpose medications and procedures to effectively combat the disease. Several groups have focused on the potential treatment utility of angiotensin-converting-enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) for hypertensive COVID-19 patients, with inconclusive evidence thus far. We couple electronic medical record (EMR) and registry data of 3,643 patients from Spain, Italy, Germany, Ecuador, and the US with a machine learning framework to personalize the prescription of ACEIs and ARBs to hypertensive COVID-19 patients. Our approach leverages clinical and demographic information to identify hospitalized individuals whose probability of mortality or morbidity can decrease by prescribing this class of drugs. In particular, the algorithm proposes increasing ACEI/ARBs prescriptions for patients with cardiovascular disease and decreasing prescriptions for those with low oxygen saturation at admission. We show that personalized recommendations can improve patient outcomes by 1.0% compared to the standard of care when applied to external populations. We develop an interactive interface for our algorithm, providing physicians with an actionable tool to easily assess treatment alternatives and inform clinical decisions. This work offers the first personalized recommendation system to accurately evaluate the efficacy and risks of prescribing ACEIs and ARBs to hypertensive COVID-19 patients.

Risk assessment for acute kidney injury and death among new COVID-19 positive adult patients without chronic kidney disease: retrospective cohort study among three US hospitals.

OBJECTIVE: To develop simple but clinically informative risk stratification tools using a few top demographic factors and biomarkers at COVID-19 diagnosis to predict acute kidney injury (AKI) and death. DESIGN: Retrospective cohort analysis, follow-up from 1 February through 28 May 2020. SETTING: 3 teaching hospitals, 2 urban and 1 community-based in the Boston area. PARTICIPANTS: Eligible patients were at least 18 years old, tested COVID-19 positive from 1 February through 28 May 2020, and had at least two serum creatinine measurements within 30 days of a new COVID-19 diagnosis. Exclusion criteria were having chronic kidney disease or having a previous AKI within 3 months of a new COVID-19 diagnosis. MAIN OUTCOMES AND MEASURES: Time from new COVID-19 diagnosis until AKI event, time until death event. RESULTS: Among 3716 patients, there were 1855 (49.9%) males and the average age was 58.6 years (SD 19.2 years). Age, sex, white blood cell, haemoglobin, platelet, C reactive protein (CRP) and D-dimer levels were most strongly associated with AKI and/or death. We created risk scores using these variables predicting AKI within 3 days and death within 30 days of a new COVID-19 diagnosis. Area under the curve (AUC) for predicting AKI within 3 days was 0.785 (95% CI 0.758 to 0.813) and AUC for death within 30 days was 0.861 (95% CI 0.843 to 0.878). Haemoglobin was the most predictive component for AKI, and age the most predictive for death. Predictive accuracies using all study variables were similar to using the simplified scores. CONCLUSION: Simple risk scores using age, sex, a complete blood cell count, CRP and D-dimer were highly predictive of AKI and death and can help simplify and better inform clinical decision making.

Noteworthy Literature published in 2017 for Cardiothoracic Anesthesiologists.

The year 2017 was a year dominated by large-scale clinical studies reporting the outcome of various interventions in cardiac surgery and heart failure (HF) patients, relevant to all cardiothoracic anesthesiologists. Among them were studies investigating the addition of levosimendan, an alternative inotropic agent, to standard management of patients with HF undergoing cardiac surgery. Also, corticosteroids have been used for various purposes in cardiac patients. Here, a new study reports the effect of high-dose methylprednisolone on recovery and delirium. Furthermore, with increasing evidence that transfusions increase morbidity and mortality, a publication reports the use of rotational thromboelastometry to reduce transfusion requirements. In addition, several randomized controlled multicenter studies report the outcomes of patients undergoing cardiac procedures: surgical versus transcatheter aortic valve replacement in intermediate-risk patients and the use of centrifugal-flow versus axial-flow left-ventricular devices in patients with HF. These studies demonstrate the dynamic and ever-evolving state of perioperative cardiovascular medicine and show us the direction of future developments.

Noteworthy Literature Published in 2016 for the Cardiothoracic Anesthesiologist.

Clinical research and outcome studies dominated the publication spectrum for the cardiothoracic anesthesiologist in 2016. Echocardiography is an important tool in the armamentarium of the cardiothoracic anesthesiologist. Technology is advancing at a fast pace: A new method to quantify the regurgitant volume in mitral regurgitation has been described in an experimental model and been validated in humans. Interesting studies on key elements of our daily practice have been published: Does tranexamic acid decrease the transfusion requirements after cardiac surgery? Are patients with a postoperative cognitive deficit at risk for dementia 7.5 years after surgery? What is the best strategy for post-cardiac surgery atrial fibrillation? What is the mechanism of preconditioning with remifentanil? Large multicenter looked at the treatment strategies for moderate and severe ischemic mitral regurgitation and benefits of transcatheter aortic valve replacement versus the surgical approach. These studies may give us ideas on how to tailor treatment to optimize the patients' outcome and to minimize the associated risks.

Noteworthy Articles in 2015 for the Cardiothoracic Anesthesiologist.

Large multicenter, randomized controlled trials published in reputable journals had a large impact on the world of cardiothoracic anesthesia in 2015. We as cardiac anesthesiologists pride ourselves as being experts in applied physiology, physics, ultrasonography, and pharmacology/pharmacotherapy. The selected studies added to our knowledge in the fields of echocardiography, pharmacology, molecular biology, and genetics. Outcome studies shine a light on important topics that are relevant to all cardiac anesthesiologists: does surgical atrial fibrillation ablation during mitral valve surgery reduce the recurrence of atrial fibrillation at 1 year after surgery? Does remote ischemic preconditioning live up to its promise to reduce postoperative major cardiac and cerebral events? Although we still do not have the answer to all the questions, the year 2015 has been a great step toward the goal of understanding molecular mechanisms of ischemic myocardial injury and toward providing evidence-based medicine for improving patient outcome.

Misplacement of a pulmonary artery catheter.

Placing a flow-directed pulmonary artery catheter (PAC) can be difficult and lead to serious complications. We present the case of an attempted PAC insertion in a patient undergoing implantation of a left ventricular assist device. Although physiologic pressure waveforms were established, plausible measurements of cardiac output and pulmonary capillary wedge pressure were not initially obtainable. Chest radiography showed that the catheter was looped in the pulmonary artery. This malposition could not be visualized intraoperatively by transesophageal echocardiography. The PAC was replaced in the operating room after the left ventricular assist device was implanted.

Rescue transoesophageal echocardiography for refractory haemodynamic instability during transvenous lead extraction.

AIMS: The rising number of cardiovascular implantable electronic devices has led to a steep increase in transvenous lead extractions (TLEs). Procedure-related, haemodynamically significant adverse events are uncommon during TLE yet remain an inevitable risk. While the use of transoesophageal echocardiography (TEE) as a guide to clinical decision-making during refractory circulatory instability has been well established, the specific utility of rescue TEE during TLE has not been comprehensively studied. METHODS AND RESULTS: Twenty-six patients who required emergent TEE to determine the aetiology of intractable haemodynamic instability during TLE were evaluated. Pericardial effusion requiring urgent pericardiocentesis and/or cardiac surgical intervention was diagnosed by TEE in 10 patients, and progressed to cardiac arrest in 4 patients. Haemorrhagic shock developed in two patients suffering from femoral vein laceration and right haemothorax, respectively. One additional patient developed acute respiratory compromise and right ventricular dysfunction diagnosed by TEE, which necessitated prolonged post-operative intubation and inotropic therapy. In 14 patients, TEE excluded life-threatening cardiovascular injuries and enabled the pursuit of continued medical management. Two patients with reassuring TEE findings underwent intra-operative placement of chest tubes for pneumothorax. All the 26 patients were discharged from the hospital. CONCLUSION: While TLE is a relatively safe procedure, life-threatening cardiovascular injuries remain a rare risk. In this study, the use of rescue TEE ruled out significant cardiovascular injuries in the majority of patients. Furthermore, rescue TEE had a substantial impact on the efficiency of determining the aetiology of refractory haemodynamic instability during TLE and thereby facilitated the timely initiation of definitive intervention.