Contemporary approach to cardiogenic shock care: a state-of-the-art review.

Cardiogenic shock (CS) is a time-sensitive and hemodynamically complex syndrome with a broad spectrum of etiologies and clinical presentations. Despite contemporary therapies, CS continues to maintain high morbidity and mortality ranging from 35 to 50%. More recently, burgeoning observational research in this field aimed at enhancing the early recognition and characterization of the shock state through standardized team-based protocols, comprehensive hemodynamic profiling, and tailored and selective utilization of temporary mechanical circulatory support devices has been associated with improved outcomes. In this narrative review, we discuss the pathophysiology of CS, novel phenotypes, evolving definitions and staging systems, currently available pharmacologic and device-based therapies, standardized, team-based management protocols, and regionalized systems-of-care aimed at improving shock outcomes. We also explore opportunities for fertile investigation through randomized and non-randomized studies to address the prevailing knowledge gaps that will be critical to improving long-term outcomes.

Impella Management for the Cardiac Intensivist.

The Impella mechanical circulatory support (MCS) system is a catheter-based continuous flow cardiac assist device that is widely used in the treatment of cardiogenic shock in medical and surgical cardiac intensive care units. As with all forms of MCS, device-related complications remain a major concern, the incidence of which can be mitigated by adhering to a few fundamental concepts in device management. The purpose of this review is to comprehensively describe our strategy for managing, repositioning, and weaning the Impella catheter.

Biologic Therapy in HIV: To Screen or Not to Screen.

Biologic therapy has revolutionized the management of chronic inflammatory diseases, including inflammatory bowel disease (IBD). Before the initiation of therapy, it is critical to rule out prior infection of chronic hepatitis B virus (HBV) and tuberculosis (TB). However, screening for human immunodeficiency virus (HIV) is not as routinely completed. We present a case of a 56-year-old male on ustekinumab for the management of Crohn's disease, found to have undiagnosed human immunodeficiency virus (HIV) with progression to acquired immunodeficiency syndrome (AIDS).

Implications of Misclassification of Type 2 Myocardial Infarction on Clinical Outcomes.

BACKGROUND: Patients with type 2 myocardial infarction (MI) are often classified under the diagnosis of non-ST-segment-elevation MI (NSTEMI) despite the significant differences in clinical characteristics, management, and outcomes between type 2 MI and type 1 NSTEMI. This may have significant implications that can lead to inaccurate assessment of quality measures by MI quality review programs. METHODS: A single-center retrospective study of 1224 patients discharged with the diagnosis of type 1 NSTEMI between January 2015 and September 2017. Based on the third universal definition of MI, we stratified patients into type 2 MI or type 1 NSTEMI. Patient's characteristics, comorbidities, medications prescribed during hospitalization and at discharge, readmissions within 30 days after discharge, and diagnostic and therapeutic interventions data was collected. The primary goal of this study was to identify how often type 2 MI patients were misclassified as type 1 NSTEMI, we also assessed the differences in treatment and outcomes between type 2 MI and type 1 NSTEMI. RESULTS: 1224 patients assigned the ICD-9 and ICD-10 codes of type 1 NSTEMI at discharge were evaluated for study inclusion. After application of the inclusion criteria, 945 patients were included in the final analysis. Of these 945 patients, 281 (29.7%) patients were classified as type 2 MI and 664 (70.3%) patients were classified as type 1 NSTEMI. Patients with type 2 MI were older, more likely to have systolic heart failure, had lower peak troponin levels, were less likely to receive aspirin, P2Y12 inhibitors and statin at discharge, and had longer length of stay. Compared with type 1 NSTEMI patients, those with type 2 MI had higher all cause 30-day mortality (13.5% versus 2.9%, P < 0.0001) (RR: 4.65; 95% CI, 2.85-9.65). After adjusting for patient demographics, comorbidities, and medications, patients with type 2 MI were still more likely to die within 30 days after discharge (RR: 2.89; 95% CI, 1.58-7.46). In addition, patients with type 2 MI were more likely to be readmitted within 30 days after discharge than patients with type 1 NSTEMI (17.7% versus 13.9%, P < 0.01) (RR: 1.27; 95% CI, 1.08-2.5). CONCLUSIONS: Close to one third of patients given the diagnosis of type 1 NSTEMI at discharge at our institution were type 2 MI patients. Patients with type 2 MI are managed differently from type 1 NSTEMI patients and have higher 30-day mortality and readmission rate. Misclassification of type 2 MI as type 1 NSTEMI can have a significant impact on hospitals MI clinical performance and quality measures.

A Band That Causes Leaky Valves: Severe Mitral Regurgitation due to Left Atrial Fibrous Band-A Case Report and Literature Review.

Left atrial fibrous band is a rare clinical and echocardiographic finding characterized by the presence of a fibrous band attached to the mitral valve. Diagnosis is accomplished with transesophageal echocardiography (TEE), live 3D imaging, or cardiac MRI. Most patients are asymptomatic and incidental findings. However, in rare cases, an atrial fibrous band can produce symptoms such as dyspnea on exertion, fatigue, and lightheadedness secondary to mitral regurgitation (MR) which can lead to heart failure if unattended to. More serious complications such as cardioembolic phenomenon can occur. We herein report a case of a 55-year-old male with hypertension who presented with dyspnea on exertion and chest pain. Transthoracic echocardiography (TTE) showed mitral valve prolapse with moderate to severe mitral regurgitation. TEE showed an atrial fibrous band. Given the patient's poor exercise tolerance, he was taken to surgery for a mitral annuloplasty.