Evaluation of procalcitonin elevation during ICU stay and its relationship with mortality in ICU patients for COVID-19 with respiratory involvement. A multicenter prospective cohort study.

Introduction: A multicenter prospective cohort study studied patients admitted to the intensive care unit (ICU) by coronavirus-19 (COVID-19) with respiratory involvement. We observed the number of occasions in which the value of procalcitonin (PCT) was higher than 0.5 ng/ml. Objective: Evaluation of PCT elevation and influence on mortality in patients admitted to the ICU for COVID-19 with respiratory involvement. Measurements and main results: We studied 201 patients. On the day of admission, acute physiology and chronic health evaluation (APACHE)-II was 13 (10-16) points. In-hospital mortality was 36.8%. During ICU stay, 104 patients presented 1 or more episodes of PCT elevation and 60 (57.7%) died and 97 patients did not present any episodes of PCT elevation and only 14 (14.4%) died (p < 0.001). Multivariable analysis showed that mortality was associated with APACHE-II: [odds ratio (OR): 1.13 (1.04-1.23)], acute kidney injury [OR: 2.21 (1.1-4.42)] and with the presentation of one or more episodes of escalating PCT: [OR: 5.07 (2.44-10.53)]. Of 71 patients who died, 59.2% had an elevated PCT value on the last day, and of the 124 patients who survived, only 3.2% had an elevated PCT value on the last day (p < 0.001). On the last day of the ICU stay, the sequential organ failure assessment (SOFA) score of those who died was 9 (6-11) and 1 (0-2) points in survivors (p < 0.001). Of the 42 patients who died and in whom PCT was elevated on the last day, 71.4% were considered to have a mainly non-respiratory cause of death. Conclusion: In patients admitted to the ICU by COVID-19 with respiratory involvement, numerous episodes of PCT elevation are observed, related to mortality. PCT was elevated on the last day in more than half of the patients who died. Serial assessment of procalcitonin in these patients is useful because it alerts to situations of high risk of death. This may be useful in the future to improve the treatment and prognosis of these patients.

Implant of permanent pacemaker during acute coronary syndrome: Mortality and associated factors in the ARIAM registry.

BACKGROUND: Patients with acute coronary syndrome complicated with high degree atrioventricular block still have a high mortality. A low percentage of these patients need a permanent pacemaker (PPM) but mortality and associated factors with the PPM implant in acute coronary syndrome patients are not known. We assess whether PPM implant is an independent variable in the mortality of acute coronary syndrome patients. Also, we explored the variables that remain independently associated with PPM implantation. METHODS: This was an observational study on the Spanish ARIAM register. The inclusion period was from January 2001 to December 2011. This registry included all Andalusian acute coronary syndrome patients. Follow-up for global mortality was until November 2013. RESULTS: We selected 27,608 cases. In 62 patients a PPM was implanted (0.024%). The mean age in PPM patients was 70.71±11.214 years versus 64.46±12.985 years in patients with no PPM. PPM implant was associated independently with age (odds ratio (OR) 1.031, 95% confidence interval (CI) 1.007-1.055), with left ventricular branch block (OR 6.622, 95% CI 2.439-18.181), with any arrhythmia at intensive care unit admission (OR 2.754, 95% CI 1.506-5.025) and with heart failure (OR 3.344, 95% CI 1.78-8.333). PPM implant was independently associated with mortality (OR 11.436, 95% CI 1.576-83.009). In propensity score analysis PPM implant was still associated with mortality (OR 5.79, 95% CI 3.27-25.63). CONCLUSION: PPM implant is associated with mortality in the acute coronary syndrome population in the ARIAM registry. Advanced age, heart failure, arrhythmias and left ventricular branch block at intensive care unit admission were found associated factors with PPM implant in acute coronary syndrome patient.

Increasing Levels of Positive End-expiratory Pressure Improve the Left Ventricular Strain.

PURPOSE: The goal of this study was to evaluate possible changes in the left myocardial performance of patients with cardiogenic shock (CS) during ascending levels of positive end-expiratory pressure (PEEP) using speckle-tracking echocardiography. MATERIALS AND METHODS: This was an interventional clinical study performed on CS patients under mechanical ventilation. These patients underwent echocardiography after 15 to 30 minutes of progressive increases in PEEP zero end-expiratory pressure (ZEEP) (PEEP 5, PEEP 10, PEEP 15 cm H2O). We evaluated the changes caused by these increasing levels of PEEP on the E/E' ratio and the parameters of left ventricular systolic and diastolic functions, including longitudinal strain (S) and strain rate (SR). Analyses of mean values were carried out using analysis of variance. RESULTS: A total of 65 CS patients were included. Their mean age was 68.58±14.61 years. Progressive increases in PEEP induced a significant decrease in the E/E' ratio (ZEEP=12.87±1.81; PEEP=5, 8.39±3.61; PEEP=10, 6.34±1.73; and PEEP=15, 7.10±0.37; P<0.0001). Although we did not find significant changes in left ventricular ejection fraction, a clear increase in left ventricular S and SR occurred (ZEEP=-13, 15±1.27; PEEP=5, -16.97±4.01; PEEP=10, -16.89±0.46; PEEP=15, -15.39±4.21; and ZEEP=-1.02±0.02; PEEP=5, -1.49±0.13; PEEP=10, -1.57±0.21; PEEP=15, -1.24±0.29, respectively; all values were significant). CONCLUSIONS: Increasing levels of PEEP improve the left ventricular S and SR. PEEP levels could modify the performance of left ventricular fibers.

Stress echocardiography in patients who experienced mechanical ventilation weaning failure.

INTRODUCTION: Critically ill patients may suffer varying degrees of temporary myocardial dysfunction during respiratory weaning that could play an important role in weaning failure. OBJECTIVES: In this study, we tried to assess the existence of temporary diastolic dysfunction during respiratory weaning. METHODS: Inclusion period is from 2006 to 2015. In this study, we included 181 ventilated patients with cardiogenic shock that were being weaned from mechanical ventilation. Twenty of those patients were successfully weaned from mechanical ventilation, and the rest (161) experienced complications in their weaning process. All patients had a left ventricular ejection fraction >0.45 and E/E' ratio≤8, did not require vasoactive drugs at that time, and did not have remaining significant ischemic disease. We divided our patients into 3 groups, as follows: A, patients who could not tolerate a T-tube and required pressure-support ventilation (82); B, patients who successfully tolerated a T-tube period (20); and C, patients who could not tolerate spontaneous breathing modes of mechanical ventilation and remained on assisted mechanical ventilation. We performed stress echocardiography for the last two groups; using dobutamine to assess diastolic function and using ephedrine to evaluate functional mitral regurgitation (MR). We estimated pulmonary capillary wedge pressure through the E/E' ratio and the flow in the pulmonary veins. RESULTS: In group A (ie, those patients who could not tolerate a T-tube trial), we observed an increase in the E/E' ratio (6.32±0.77 vs 15.2±6.65; P=.0001) and a worsening of strain (S) and strain rate (SR) (-13.6±1.80 vs -11.88±5.6, P=.0001; and -1.3±1.28 vs -0.95±0.38, P=.0001; respectively). We did not observe a change in the E/E' ratio during stress echocardiogram on those patients with successful weaning from mechanical ventilation (7.41±0.43 vs 8.38±4.57, P=.001). However, we did see in this group an increased peak velocity of the S wave and of SR (-16.11±08.72 vs -19.89±5.62 and -1.48±0.23 vs -1.59±0.21, P=.001; respectively). In 42 weaning failure patients, the dobutamine echocardiography showed an increased E/E' ratio (7.41±0.43 vs 15.98±7.98; P=.0001) and deterioration of S (-15.41±09.56 vs -12.72±6.55; P=.0001) and SR (-1.41±0.78 vs -1.22±0.65; P=.0001). In 37 patients without systolic or diastolic impairment and functional MR grade >2, ephedrine echocardiography showed an increase of effective regurgitant volume (29.56±11.32 mL vs 46.56±0.13 mL, P=.0001) and effective regurgitant orifice area (0.19±0.09 cm2 vs 0.31±0.09 cm2, P=.0001). CONCLUSIONS: Stress echocardiography may be helpful in detecting silent diastolic and systolic dysfunction or severe MR that could have a major impact on respiratory weaning.

Takotsubo cardiomyopathy--a clinical review.

Stress cardiomyopathy is characterised by reversible left ventricular dysfunction. It simulates an acute coronary syndrome (ACS), presenting with precordial pain or dyspnoea, changes of the ST segment, T wave, or QTc interval on electrocardiogram, and raised cardiac enzymes. Typical findings are disturbances of segmental contractility (apical hypokinesia or akinesia), with normal epicardial coronary arteries. The true prevalence is unknown, as the syndrome may be under-diagnosed; it is more common in postmenopausal women. There is usually a trigger in the form of physical or psychological stress. The electrocardiographic, echocardiographic, and ventriculographic changes resolve spontaneously over a variable period of time (from days to months). There are a number of pathophysiological theories, none of which has been shown to be definitive, suggesting that all of them may be involved to some extent. The prognosis is generally favourable, and recurrence is very rare.

Evaluation of the performance of echocardiography in acute coronary syndrome patients during their stay in coronary units.

OBJECTIVES: To evaluate the frequency and the factors associated with performance of echocardiography in acute coronary syndrome (ACS) patients during their stay in intensive care units or coronary care units (ICU/CCU). METHODS: Retrospective cohort study including all patients diagnosed with acute coronary syndrome-unstable angina (UA), acute myocardial infarction (AMI)-included in the 'ARIAM' Spanish multi-centre register. The study period was from June 1996 to December 2005. The follow-up period is limited to the time of stay in the Intensive Care Units or Coronary Care Units (ICUs/CCUs). A univariate analysis was carried out on the patients with UA and AMI according to whether or not echocardiograms were performed during their stay in ICU/CCU. In addition the data was evaluated for any temporal variation in the performance of echocardiography, and two multivariate analyses were carried out to evaluate the factors associated with performance of echocardiography in UA and AMI patients. RESULTS: The study period included 45,688 AMI patients and 17,277 UA patients. Echocardiograms were performed in 26.87% AMI patients and 16.75% UA patients. In total, 15,172 echocardiograms were performed in ACS patients (23.6%). The multivariate analysis demonstrated that the variables associated with the performance of echocardiography in UA were: Killip and Kimball class, cigarette smoking, family history of cardiovascular events, cardiogenic shock, uncontrolled angina, mechanical ventilation and treatment with ACE inhibitors, while the presence of previous AMI was associated with fewer echocardiograms being performed. In AMI, the multivariate analysis showed the following variables to be associated with the performance of echocardiography: Killip and Kimball class, Q-AMI, right heart failure, the need for insertion of Swan-Ganz catheter, cardiogenic shock, high-degree AV block and the administration of ACE inhibitors, while age was associated with fewer being performed. Over the 10 years of the study period, there was a discrete but significant increase in the use of echocardiography in patients in ICU/CCU. CONCLUSIONS: Echocardiography is not commonly used in ACS patients while in ICU/CCU. UA and AMI patients who did have echocardiograms during their stay in ICU/CCU were chiefly those presenting heart failure and major complications, and represent a subpopulation with poor prognosis. The performance of echocardiography in ACS patients increased slightly over the length of their stay in ICU/CCU.

Administration of intrapericardial tissue adhesive after cardiac rupture and cardiac tamponade.

OBJECTIVE: To describe a series of patients treated with intrapericardial glue. DESIGN: Case reports. Descriptive study. PATIENTS: We describe the results obtained using the injection of a surgical intrapericardial adhesive in 19 patients who presented cardiac tamponade and shock after cardiac rupture. The technique was done using puncture and echocardiographic subxiphoid control. At the one-year follow-up, 5 patients had survived, with neither pseudoaneurysms nor constriction. One patient was injected with said adhesive in the right ventricular cavity. CONCLUSIONS: Pericardial drainage, followed by the administration of intrapericardial glue may be an attractive technique. This technique should be studied for its possible utility when faced with surgical impossibility.

Heart rupture predictors in Spanish myocardial infarction patients: evaluation using propensity score analysis.

BACKGROUND: The aim was to evaluate factors associated with the development of heart rupture in a Spanish registry of acute myocardial infarction (AMI) patients. MATERIAL/METHODS: This was a retrospective study of cohorts, including all patients diagnosed with AMI included in the ARIAM Spanish multicenter registry. The study period was from June 1996 to December 2005. The follow-up period was limited to the time of stay in intensive care or coronary care units. Multivariate logistic regression was used to study the factors associated with the development of heart rupture. A propensity score analysis was also performed to determine the involvement of beta blockers, ACE inhibitors, and fibrinolytics in the development of heart rupture. RESULTS: 16,815 AMI patients were included. Heart rupture occurred in 477 (2.8%). Heart rupture was associated with female gender, older age, the absence of previous infarct, and the administration of thrombolysis, while ACE inhibitors and beta blockers acted as protective variables. The propensity score analysis showed that fibrinolysis was a variable associated with heart rupture except in the younger subgroup and in the subgroup with less delay in administration. It was also found that beta blockers and ACE inhibitors are variables providing protection against heart rupture. CONCLUSIONS: Heart rupture is associated with older age, female gender, absence of previous infarct, and the administration of thrombolysis, while ACE inhibitors and beta blockers seem to prevent this complication.

Sustained ventricular arrhythmias in unstable angina patients: results of the ARIAM database.

BACKGROUND: The aim of this study was to investigate patients with unstable angina (UA) and the predictive factors of these arrhythmias and to determine whether this complication behaves as an independent variable with regard to mortality, increased length of stay in an ICU/CCU, and the performance of percutaneous coronary intervention (PCI). MATERIAL/METHODS: The retrospective cohort study included all patients diagnosed with UA and included in the Spanish "ARIAM" database between June 1996 and December 2005. Univariate and multivariate analyses were performed to evaluate the factors associated with these arrhythmias. 17,616 patients were included. RESULTS: Sustained ventricular tachycardia (SVT) occurred in 0.5%. The factors associated with its development were age, cardiogenic shock, and non-sustained ventricular tachycardia. SVT was associated with mortality (adjusted OR: 9.836, 95%CI: 1.81-53.33). Ventricular fibrillation (VF) occurred in 1%. In the multivariate study the variables that persistently associated independently with the development of VF were gender, Killip class, and high degree atrioventricular block (HDAVB). VF was associated with higher mortality (27.1% vs. 0.9%). Nevertheless, VF was not seen to be a variable independently associated with mortality in UA patients. Only VF was an independent variable in length of stay (adjusted OR: 2.059, 95%CI: 1.175-3.609). Neither SVT nor VF were independent variables associated with PCI. CONCLUSIONS: Patients with UA complicated by SVT or VF represent a special high-risk subgroup with poor prognosis, which could lead to their being stratified towards a poor prognosis subgroup.

Cardiogenic shock in acute coronary syndrome.

This is a review of current knowledge on cardiogenic shock (CS), with particular attention to recommended management. The bibliography for the study was compiled through a search of different databases between 1966-2008. The references cited in the selected articles were also reviewed. The selection criteria included all reports published on CS, from case reports and case series to controlled studies. Languages used were Spanish, French, Italian, Portuguese, German, and English. Cardiogenic shock is the most frequent cause of in-hospital death as a complication of acute coronary syndrome. The incidence is about 7% and, despite therapeutic advances, it continues to have an ominous prognosis, with mortality rates of over 50%. Coronary reperfusion is fundamental in the management of cardiogenic shock, particularly with the use of percutaneous coronary intervention. However, if this is not available, systemic thrombolysis may be performed together with balloon counterpulsation or the use of pressor drugs. Despite the historical importance of the Swan-Ganz catheter, this would appear to have limited use, with echocardiography nonetheless having a fundamental role in the management of CS. Although patients with cardiogenic shock often present a left ventricular ejection fraction of around 30%, survivors often have a good functional classification one year after the event. Neurohormonal and inflammatory mechanisms play a fundamental role in the pathophysiology of CS. These mechanisms are currently the target of studies looking into developing new therapeutic strategies.

Cardiogenic shock in acute coronary syndrome in the Spanish population.

BACKGROUND: To evaluate the frequency and factors associated with cardiogenic shock (CS) in acute myocardial infarction (AMI) and unstable angina (UA) and percutaneous coronary intervention (PCI). MATERIAL/METHODS: Spanish registry. The study period was June 1996 to December 2005. Follow-up was length of stay in an intensive care or coronary care unit (ICU/CCU). Multivariate studies evaluated factors associated with CS, mortality in CS, and PCI performance. RESULTS: The study included 45.688 AMI patients and 17.277 UA patients. Cardiogenic shock occurred in 9.3% of patients with AMI and 1.79% of those with UA, frequencies that decreased over time. Variables associated with cardiogenic shock in AMI patients were female sex, age, type of infarction, diabetes, previous stroke, arrhythmia, previous angiography, complicated angina, and reinfarction. Hypertension and oral beta-blocking, ACE inhibitor, and hypolipidemic agents protected against CS. In UA, these variables were age, previous angina or AMI, right ventricular heart failure, arrhythmia. Beta-blocking agents were associated with a reduction in CS. Deaths from CS and AMI, respectively, were 62.8% and 38.7% in persons with UA. Doing PCIs has increased significantly; it is more prevalent in ex-smokers and those with right ventricular heart failure and mechanical ventilation; lower performance is associated with need for cardiopulmonary resuscitation; patients who die are older or have a history of AMI. CONCLUSIONS: There has been a slight drop in the frequency of CS and its mortality. Factors associated with CS are similar to those associated with acute coronary syndromes. The frequency of PCI was low.

Giant right atrial thrombi treated with thrombolysis.

The present report describes giant atrial thrombi that were treated with thrombolysis in a community hospital. Two patients with giant atrial thrombi whose treatment involved complications are presented. Both patients developed cardiogenic shock and were treated unsuccessfully with thrombolysis. Because thrombolysis of giant thrombi may be ineffective, patients in this situation may require surgery.

[Mean length of stay and prognosis in unstable angina. Results from the ARIAM database]. / Estancia media y pronóstico en la angina inestable. Resultados del registro ARIAM.

BACKGROUND AND OBJECTIVE: The objective of this project is to investigate the factors predicting mortality and mean length of stay in patients diagnosed with unstable angina (UA) during admission to the Intensive Care Unit or Critical Care Unit (ICU/CCU). PATIENTS AND METHOD: A retrospective cohort study including all the UA patients listed in the Spanish ARIAM register. The study period comprised from June, 1996 to December, 2003. The follow-up period is limited to the stay in the ICU/CCU. One univariate analysis was performed between deceased and live patients; and another between prolonged and non-prolonged stay patients. Three multivariate analyses were also performed; one to evaluate the factors related to mortality, another to evaluate the variables associated to percutaneous coronary intervention (PCI) and another to evaluate the factors associated to the prolonged mean stay in ICU/CCU. RESULTS: 14,096 patients with UA were included in the study. The UA mortality rate during ICU/CCU admission was 1.1%. Mortality was associated to Killip classification, age, the need for CPR, development of cardiogenic shock, development of arrhythmia (such as VF, sinus tachycardia or high-degree atrioventricular block) and diabetes; whereas patients who smoke were associated to a lower mortality rate. PCI was only performed in 1,226 patients (8.9%), increasing over the years. The PCI-predicting variables were: age, being referred from another hospital, smoking, presenting prior acute myocardial infarction (AMI), complications consisting of cardiogenic shock or high-degree atrioventricular block and being treated with oral beta blockers. The mean length of stay in ICU/CCU was 3.15 (18.65) days (median, 2 days), depending on age, a coronariography having previously been performed, the Killip classification, having required coronariography and PCI or echocardiography or mechanical ventilation, and presenting complications such as angina that is difficult to control, arrhythmia, right ventricular failure or death. CONCLUSIONS: The factors are associated to mortality were; greater age, diabetes, Killip classification, arrhythmia, cardiogenic shock and the need for CPR, whereas smoking is associated to a lower mortality rate. The patients on whom PCI was performed represent a less severe population. Management has changed over the years, with an increase in PCI. A prolonged mean length of stay is associated to the appearance of arrhythmia, right or left heart failure, angina that is difficult to control, age and PCI.

Estancia media y pronóstico en la angina inestable. Resultados del registro ARIAM / Mean length of stay and prognosis in unstable angina. Results from the ARIAM database

Fundamento y objetivo: El propósito de este trabajo es investigar los factores predictores de mortalidad y la estancia media de los pacientes diagnosticados de angina inestable (AI) durante su ingreso en las unidades de cuidados intensivos o unidades de cuidados coronarios (UCI/UCC). Pacientes y método: Estudio de cohorte retrospectivo que incluyó a los pacientes del registro español ARIAM (Análisis del Retraso en el Infarto Agudo de Miocardio). El período de estudio comprendió de junio de 1996 a diciembre de 2003. Su seguimiento se limitó a UCI/UCC. Se realizó un análisis univariante entre los pacientes fallecidos y los vivos y otro entre los pacientes con estancia prolongada y no prolongada. Se realizaron además 3 análisis multivariantes con el objetivo de evaluar los factores relacionados con la mortalidad, las variables asociadas a la realización de intervención coronaria percutánea (ICP) y los factores asociados a la estancia media prolongada en UCI/UCC. Resultados: Se incluyó a 14.096 pacientes con AI. La mortalidad fue del 1,1% y se asoció a la clase Killip, edad, necesidad de reanimación cardiopulmonar y presencia de shock cardiogénico, arritmias y diabetes; mientras que los pacientes fumadores se asociaron a una menor mortalidad. Se realizó ICP sólo a 1.226 (8,9%) pacientes, aunque su realización se incrementó con los años. La ICP se asoció a edad, traslado interhospitalario, tabaquismo, infarto de miocardio previo, shock cardiogénico o ante el bloqueo auriculoventricular de alto grado (BAVAG) y tratamiento con bloqueadores beta. La estancia media (desviación estándar) fue de 3,15 (18,65) días. La estancia media prolongada dependió de la edad, haber sido sometido a una coronariografía o ICP, clase Killip, ecocardiografía o ventilación mecánica y presentar complicaciones graves. Conclusiones: La mortalidad se explica por la comorbilidad y la gravedad de la isquemia. Los pacientes a los que se realiza ICP son una población menos grave, y su realización con el tiempo se incrementa. La estancia media prolongada se asocia a la mayor gravedad de la isquemia miocárdica y a la ICP

Background and objective: The objective of this project is to investigate the factors predicting mortality and mean length of stay in patients diagnosed with unstable angina (UA) during admission to the Intensive Care Unit or Critical Care Unit (ICU/CCU). Patients and method: A retrospective cohort study including all the UA patients listed in the Spanish ARIAM register. The study period comprised from June, 1996 to December, 2003. The follow-up period is limited to the stay in the ICU/CCU. One univariate analysis was performed between deceased and live patients; and another between prolonged and non-prolonged stay patients. Three multivariate analyses were also performed; one to evaluate the factors related to mortality, another to evaluate the variables associated to percutaneous coronary intervention (PCI) and another to evaluate the factors associated to the prolonged mean stay in ICU/CCU. Results: 14,096 patients with UA were included in the study. The UA mortality rate during ICU/CCU admission was 1.1%. Mortality was associated to Killip classification, age, the need for CPR, development of cardiogenic shock, development of arrhythmia (such as VF, sinus tachycardia or high-degree atrioventricular block) and diabetes; whereas patients who smoke were associated to a lower mortality rate. PCI was only performed in 1,226 patients (8.9%), increasing over the years. The PCI-predicting variables were: age, being referred from another hospital, smoking, presenting prior acute myocardial infarction (AMI), complications consisting of cardiogenic shock or high-degree atrioventricular block and being treated with oral beta blockers. The mean length of stay in ICU/CCU was 3.15 (18.65) days (median, 2 days), depending on age, a coronariography having previously been performed, the Killip classification, having required coronariography and PCI or echocardiography or mechanical ventilation, and presenting complications such as angina that is difficult to control, arrhythmia, right ventricular failure or death. Conclusions: The factors are associated to mortality were; greater age, diabetes, Killip classification, arrhythmia, cardiogenic shock and the need for CPR, whereas smoking is associated to a lower mortality rate. The patients on whom PCI was performed represent a less severe population. Management has changed over the years, with an increase in PCI. A prolonged mean length of stay is associated to the appearance of arrhythmia, right or left heart failure, angina that is difficult to control, age and PCI