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2.
Circ Heart Fail ; 12(11): e006635, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31707801

RESUMO

BACKGROUND: Temporary mechanical circulatory support (MCS) devices provide hemodynamic assistance for shock refractory to pharmacological treatment. Most registries have focused on single devices or specific etiologies of shock, limiting data regarding overall practice patterns with temporary MCS in cardiac intensive care units. METHODS: The CCCTN (Critical Care Cardiology Trials Network) is a multicenter network of tertiary CICUs in North America. Between September 2017 and September 2018, each center (n=16) contributed a 2-month snapshot of consecutive medical CICU admissions. RESULTS: Of the 270 admissions using temporary MCS, 33% had acute myocardial infarction-related cardiogenic shock (CS), 31% had CS not related to acute myocardial infarction, 11% had mixed shock, and 22% had an indication other than shock. Among all 585 admissions with CS or mixed shock, 34% used temporary MCS during the CICU stay with substantial variation between centers (range: 17%-50%). The most common temporary MCS devices were intraaortic balloon pumps (72%), Impella (17%), and veno-arterial extracorporeal membrane oxygenation (11%), although intraaortic balloon pump use also varied between centers (range: 40%-100%). Patients managed with intraaortic balloon pump versus other forms of MCS (advanced MCS) had lower Sequential Organ Failure Assessment scores and less severe metabolic derangements. Illness severity was similar at high- versus low-MCS utilizing centers and at centers with more advanced MCS use. CONCLUSIONS: There is wide variation in the use of temporary MCS among patients with shock in tertiary CICUs. While hospital-level variation in temporary MCS device selection is not explained by differences in illness severity, patient-level variation appears to be related, at least in part, to illness severity.

3.
Eur Heart J Acute Cardiovasc Care ; : 2048872619883354, 2019 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-31642690

RESUMO

BACKGROUND: Vorapaxar inhibits the thrombin-mediated activation of platelets, reduces thrombotic events in patients with myocardial infarction or peripheral arterial disease while increasing bleeding. In the TRA 2°P-TIMI 50 trial, we observed a nominally significant interaction between low body weight and the reduced efficacy of vorapaxar. METHODS: We investigated the relationship between body weight and the efficacy and safety of vorapaxar within a multinational, randomized, double-blind, placebo-controlled trial of vorapaxar in patients with atherosclerosis. This analysis was performed among 20,138 patients with a clinical indication for vorapaxar. RESULTS: Compared with patients weighing 60 kg or more, patients weighing less than 60 kg were older, more frequently women, Asian and had renal insufficiency (each P<0.001). The efficacy of vorapaxar with respect to cardiovascular death, myocardial infarction and stroke showed a significant interaction with patients' weight (Pinteraction<0.03). However among patients younger than 65 years, vorapaxar reduced the primary endpoint regardless of weight (weight ≥60 kg: 6.4% vs. 8.1%, hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.65-0.86; weight <60 kg: 5.4% vs. 7.2%, HR 0.75, 95% CI 0.37-1.49, Pinteraction=0.98). Among patients aged 65 years and older, the efficacy of vorapaxar diminished in patients weighing less than 60 kg (high weight: 10.4% vs. 12.6%, HR 0.81, 95% CI 0.69-0.95; low weight: 16.1% vs. 9.0%, HR 1.62, 95% CI 0.95-2.76, Pinteraction=0.01). The relative increase in bleeding with vorapaxar was not modified by weight (all Pinteraction>0.05). CONCLUSIONS: Vorapaxar reduced vascular events and improved net clinical outcome regardless of body weight in younger patients. Elderly patients with low weight may not be good candidates for aggressive secondary prevention with vorapaxar added to standard therapy. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov Unique identifier: NCT00526474.

4.
J Am Heart Assoc ; 8(17): e013675, 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31462130

RESUMO

Background There are no risk scores designed specifically for mortality risk prediction in unselected cardiac intensive care unit (CICU) patients. We sought to develop a novel CICU-specific risk score for prediction of hospital mortality using variables available at the time of CICU admission. Methods and Results A database of CICU patients admitted from January 1, 2007 to April 30, 2018 was divided into derivation and validation cohorts. The top 7 predictors of hospital mortality were identified using stepwise backward regression, then used to develop the Mayo CICU Admission Risk Score (M-CARS), with integer scores ranging from 0 to 10. Discrimination was assessed using area under the receiver-operator curve analysis. Calibration was assessed using the Hosmer-Lemeshow statistic. The derivation cohort included 10 004 patients and the validation cohort included 2634 patients (mean age 67.6 years, 37.7% females). Hospital mortality was 9.2%. Predictor variables included in the M-CARS were cardiac arrest, shock, respiratory failure, Braden skin score, blood urea nitrogen, anion gap and red blood cell distribution width at the time of CICU admission. The M-CARS showed a graded relationship with hospital mortality (odds ratio 1.84 for each 1-point increase in M-CARS, 95% CI 1.78-1.89). In the validation cohort, the M-CARS had an area under the receiver-operator curve of 0.86 for hospital mortality, with good calibration (P=0.21). The 47.1% of patients with M-CARS <2 had hospital mortality of 0.8%, and the 5.2% of patients with M-CARS >6 had hospital mortality of 51.6%. Conclusions Using 7 variables available at the time of CICU admission, the M-CARS can predict hospital mortality in unselected CICU patients with excellent discrimination.

5.
J Am Coll Cardiol ; 74(8): 1057-1068, 2019 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-31439215

RESUMO

BACKGROUND: Addition of ezetimibe to statin therapy reduces the risk of recurrent cardiovascular (CV) events in patients with prior acute coronary syndrome (ACS). The role of biomarkers in identifying subsets of patients who may derive greater clinical benefit with ezetimibe is unknown. OBJECTIVES: This study sought to evaluate the role of established CV biomarkers in assessing likely benefit with ezetimibe added to statin therapy in post-ACS patients. METHODS: In a pre-specified nested analysis within a randomized, double-blind trial of ezetimibe/simvastatin versus placebo/simvastatin (IMPROVE-IT [Improved Reduction of Outcomes: Vytorin Efficacy International Trial]), high-sensitivity troponin T, N-terminal pro-B-type natriuretic peptide, growth-differentiation factor-15, and high-sensitivity C-reactive protein was measured in 7,195 patients stabilized (1 month post-randomization) after ACS. A multimarker approach based on biomarker values was used to examine the risk of recurrent CV events and clinical benefit with ezetimibe. RESULTS: Elevated levels of each biomarker were independently associated with higher risks of CV death/myocardial infarction/stroke and CV death/heart failure (ptrend < 0.001 for each). There was a pattern of greater absolute risk reduction in CV death/myocardial infarction/stroke with the addition of ezetimibe to statin therapy in patients at higher risk on the basis of biomarker levels. High-risk patients (≥3 biomarkers "positive"; n = 1,437) had an absolute risk difference of -7.3% (95% confidence interval: -13.8% to -0.8%; p = 0.02) with ezetimibe, and intermediate-risk patients (1 to 2 biomarkers positive; n = 3,842) had an absolute risk difference of -4.4% (95% confidence interval: -9.7% to 0.8%), translating into numbers needed to treat at 7 years of 14 and 23, respectively. Low-risk patients (0 biomarkers positive; n = 1,916) did not appear to benefit from the addition of ezetimibe to statin therapy. CONCLUSIONS: A biomarker-based strategy identifies a gradient of risk among patients post-ACS, offering the potential to identify higher-risk patients with a correspondingly high absolute benefit from the addition of ezetimibe to statin therapy.

6.
Circulation ; 140(20): 1661-1678, 2019 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-31416350

RESUMO

Although coronary thrombus overlying a disrupted atherosclerotic plaque has long been considered the hallmark and the primary therapeutic target for acute myocardial infarction (MI), multiple other mechanisms are now known to cause or contribute to MI. It is further recognized that an MI is just one of many types of acute myocardial injury. The Fourth Universal Definition of Myocardial Infarction provides a taxonomy for acute myocardial injury, including 5 subtypes of MI and nonischemic myocardial injury. The diagnosis of MI is reserved for patients with myocardial ischemia as the cause of myocardial injury, whether attributable to acute atherothrombosis (type 1 MI) or supply/demand mismatch without acute atherothrombosis (type 2 MI). Myocardial injury in the absence of ischemia is categorized as acute or chronic nonischemic myocardial injury. However, optimal evaluation and treatment strategies for these etiologically distinct diagnoses have yet to be defined. Herein, we review the epidemiology, risk factor associations, and diagnostic tools that may assist in differentiating between nonischemic myocardial injury, type 1 MI, and type 2 MI. We identify limitations, review new research, and propose a framework for the diagnostic and therapeutic approach for patients who have suspected MI or other causes of myocardial injury.

7.
JAMA Cardiol ; 2019 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-31339509

RESUMO

Importance: Single-center and claims-based studies have described substantial changes in the landscape of care in the cardiac intensive care unit (CICU). Professional societies have recommended research to guide evidence-based CICU redesigns. Objective: To characterize patients admitted to contemporary, advanced CICUs. Design, Setting, and Participants: This study established the Critical Care Cardiology Trials Network (CCCTN), an investigator-initiated multicenter network of 16 advanced, tertiary CICUs in the United States and Canada. For 2 months in each CICU, data for consecutive admissions were submitted to the central data coordinating center (TIMI Study Group). The data were collected and analyzed between September 2017 and 2018. Main Outcomes and Measures: Demographics, diagnoses, management, and outcomes. Results: Of 3049 participants, 1132 (37.1%) were women, 797 (31.4%) were individuals of color, and the median age was 65 years (25th and 75th percentiles, 55-75 years). Between September 2017 and September 2018, 3310 admissions were included, among which 2557 (77.3%) were for primary cardiac problems, 337 (10.2%) for postprocedural care, 253 (7.7%) for mixed general and cardiac problems, and 163 (4.9%) for overflow from general medical ICUs. When restricted to the initial 2 months of medical CICU admissions for each site, the primary analysis population included 3049 admissions with a high burden of noncardiovascular comorbidities. The top 2 CICU admission diagnoses were acute coronary syndrome (969 [31.8%]) and heart failure (567 [18.6%]); however, the proportion of acute coronary syndrome was highly variable across centers (15%-57%). The primary indications for CICU care included respiratory insufficiency (814 [26.7%]), shock (643 [21.1%]), unstable arrhythmia (521 [17.1%]), and cardiac arrest (265 [8.7%]). Advanced CICU therapies or monitoring were required for 1776 patients (58.2%), including intravenous vasoactive medications (1105 [36.2%]), invasive hemodynamic monitoring (938 [30.8%]), and mechanical ventilation (652 [21.4%]). The overall CICU mortality rate was 8.3% (95% CI, 7.3%-9.3%). The CICU indications that were associated with the highest mortality rates were cardiac arrest (101 [38.1%]), cardiogenic shock (140 [30.6%]), and the need for renal replacement therapy (51 [34.5%]). Notably, patients admitted solely for postprocedural observation or frequent monitoring had a mortality rate of 0.2% to 0.4%. Conclusions and Relevance: In a contemporary network of tertiary care CICUs, respiratory failure and shock predominated indications for admission and carried a poor prognosis. While patterns of practice varied considerably between centers, a substantial, low-risk population was identified. Multicenter collaborative networks, such as the CCCTN, could be used to help redesign cardiac critical care and to test new therapeutic strategies.

8.
Am Heart J ; 215: 12-19, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31260901

RESUMO

Prior studies have demonstrated that the cardiac intensive care unit (CICU) patient population has evolved over time. We sought to describe the temporal changes in comorbidities, illness severity, diagnoses, procedures and adjusted mortality within our CICU practice in recent years. METHODS: We retrospectively reviewed unique CICU admissions at the Mayo Clinic from January 2007 to April 2018. Comorbidities, severity of illness scores, discharge diagnosis codes and CICU procedures and therapies were recorded, and temporal trends were assessed using linear regression and Cochran-Armitage trend tests. Trends in adjusted hospital mortality over time were assessed using multivariable logistic regression. RESULTS: We included 12,418 patients with a mean age of 67.6 years (including 37.7% females). Temporal trends in the prevalence of several comorbidities and discharge diagnoses were observed, reflecting an increase in the prevalence of non-coronary cardiovascular diseases, critical care diagnoses, and organ failure (all P ≪ .05). The use of several CICU therapies and procedures increased over time, including mechanical ventilation, invasive lines and vasoactive drugs (all P ≪ .05). A temporal decrease in adjusted hospital mortality was observed among the subgroup of patients with (adjusted OR per year 0.97, 95% CI 0.94-0.99, P = .023) and without (adjusted OR per year 0.91, 95% CI 0.85-0.96, P = .002) a critical care discharge diagnosis. CONCLUSIONS: We observed an increasing prevalence of critical care and organ failure diagnoses as well as increased utilization of critical care therapies in this CICU cohort, associated with a decrease in risk-adjusted hospital mortality over time.

10.
Artigo em Inglês | MEDLINE | ID: mdl-31225598

RESUMO

AIMS: The incidence and outcomes of a requirement for non-invasive ventilation (NIV) or invasive mechanical ventilation (IMV) in acute heart failure (AHF) hospitalization are not clearly established. Thus, we aimed to characterize the incidence and trends in use of IMV and NIV in AHF and to estimate the magnitude of hazard for mortality associated with requiring IMV and NIV in AHF. METHODS AND RESULTS: We used the National Inpatient Sample (NIS) to identify AHF hospitalizations between 2008 and 2014. The exposure variable of interest was IMV or NIV use within 24 hours of hospital admission compared to no respiratory support. We analyzed the association between ventilation strategies and in-hospital mortality using Cox proportional hazards models adjusting for demographics and co-morbidities. We included 6,534,675 hospitalizations for AHF. Of these, 271,589 (4.16%) included NIV and 51,459 (0.79%) included IMV within the first 24 hours of hospitalization and rates of NIV and IMV use increased over time. In-hospital mortality for AHF hospitalizations including NIV was 5.0% and 27% for IMV compared with 2.1% for neither (P < 0.001 for both). In an adjusted model, requirement for NIV was associated with over 2 fold higher risk for in-hospital mortality (HR 2.10, 95% CI 2.01-2.19, P < 0.001) and requirement for IMV was associated with over 3 fold higher risk for in-hospital mortality (HR 3.39, 95% CI 3.14-3.66, P < 0.001). CONCLUSION: Respiratory support is used in many AHF hospitalizations, and AHF patients who require respiratory support are at high risk for in-hospital mortality. Our work should inform prospective intervention trials and quality improvement ventures in this high-risk population.

11.
Eur Heart J ; 40(40): 3345-3352, 2019 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-31093657

RESUMO

AIMS: Circulating high-sensitivity cardiac troponin (hsTn) and soluble ST2 (sST2) reflect myocardial stress in patients with heart failure (HF). Production of cyclic guanosine 3'5' monophosphate (cGMP) in response to activation of natriuretic peptide receptors reduces cardiac afterload and preload. We assessed the effects of sacubitril/valsartan on these biomarkers in patients with reduced ejection fraction and acute decompensated HF (ADHF). METHODS AND RESULTS: PIONEER-HF was a randomized, double-blind trial of sacubitril/valsartan vs. enalapril in hospitalized patients with ADHF following haemodynamic stabilization. We measured circulating hsTnT, sST2, and urinary cGMP at baseline, 1, 2 (sST2, cGMP), 4, and 8 weeks (n = 694 with all baseline biomarkers). Ratios of geometric means (timepoint/baseline) were determined and compared as a ratio for sacubitril/valsartan vs. enalapril. Compared with enalapril, sacubitril/valsartan led to a significantly greater decline in hsTnT and sST2. This effect emerged as early as 1 week for sST2 and was significant for both at 4 weeks with a 16% greater reduction in hsTnT (P < 0.001) and 9% greater reduction in sST2 (P = 0.0033). Serial urinary cGMP increased with sacubitril/valsartan compared with enalapril (P < 0.001, 1 week). The significant differences between treatment groups for each biomarker were sustained at 8 weeks. In an exploratory multivariable-adjusted analysis of cardiovascular death or HF-rehospitalization, the concentrations of hsTnT, sST2 at week 1 were significantly associated with subsequent outcome. CONCLUSION: Biomarkers of myocardial stress are elevated in patients with ADHF and associated with outcome. Compared with enalapril, sacubitril/valsartan reduces myocardial injury and haemodynamic stress as reflected by biomarkers, with an onset that is apparent within 1-4 weeks. CLINICAL TRIALS REGISTRATION: NCT02554890 clinical.trials.gov.

14.
J Am Heart Assoc ; 8(9): e011444, 2019 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-31020897

RESUMO

Background Small studies have suggested an association between markers of collagen turnover and adverse outcomes in heart failure ( HF ). We examined C-terminal telopeptide (beta- CT x) and the risk of cardiovascular death or new or worsening HF in non- ST -elevation acute coronary syndrome. Methods and Results We measured baseline serum beta- CT x, NT -pro BNP (N-terminal pro-B-type natriuretic peptide), hsTnT (high-sensitivity cardiac troponin T) and hs CRP (high-sensitivity C-reactive protein) (Roche Diagnostics) in a nested biomarker analysis (n=4094) from a study of patients with non- ST -elevation acute coronary syndrome. The relationship between quartiles of beta- CT x and cardiovascular death or HF over a median follow-up time of 12 months was analyzed using adjusted Cox models. Higher beta- CT x levels identified a significantly higher risk of cardiovascular death/ HF (Q4 10.9% versus Q1 3.8%, Logrank P<0.001). After multivariable adjustment, beta- CT x in the top quartile (Q4) was associated with cardiovascular death/ HF (Q4 versus Q1: adjusted hazard ratio 2.22 [1.50-3.27]) and its components (Q4 versus Q1: cardiovascular death: adjusted hazard ratio 2.48 [1.46-4.21]; HF : adjusted hazard ratio 2.04 [1.26-3.30]). In an adjusted multimarker model including NT -pro BNP , hsTnT, and hs CRP , beta- CT x remained independently associated with cardiovascular death/ HF (Q4 versus Q1: adjusted hazard ratio 1.98 [1.34-2.93]) and its components. Beta- CT x correlated weakly with NT -pro BNP ( r=0.17, P<0.001) and left ventricular ejection fraction ( r=-0.05, P=0.008) and did not correlate with hsTnT ( r=0.02, P=0.20), or hs CRP ( r=-0.03, P=0.09). Conclusions Levels of beta- CT x, a biomarker of collagen turnover, were associated with cardiovascular death and HF in patients with non- ST -elevation acute coronary syndrome. This biomarker, which correlated only weakly or not significantly with traditional biomarkers of cardiovascular death and HF , may provide complementary pathobiological insight and risk stratification in these patients.

15.
J Am Coll Cardiol ; 73(14): 1792-1794, 2019 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-30975296
16.
Eur Heart J Acute Cardiovasc Care ; 8(7): 660-666, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30977391

RESUMO

AIMS: Registries have reported large inter-hospital differences in intensive care unit admission rates for patients with acute heart failure, but little is known about the potential economic impact of over-admission of low-risk patients with heart failure to higher cost intensive care units. We described the variability in intensive care unit admission practices, the provision of critical care therapies, and estimated the potential national cost savings if all hospitals adopted low intensive care unit admission practices for patients admitted with heart failure. METHODS: Using a national population health dataset, we identified 349,693 heart failure admission hospitalisations with a primary diagnosis of heart failure between 2007 and 2016. Hospitals were categorised as low (first quartile), medium (second and third quartile) and high (fourth quartiles) intensive care unit utilisation. RESULTS: The mean intensive care unit admission rate was 16.4% (inter-hospital range 0.3-51%) including 5.4% in low, 14.5% in medium and 30% in high utilisation hospitals. Intensive care unit therapies in low, medium and high intensive care unit utilisation hospitals were 54.5%, 45.1% and 24.1% (P<0.001), respectively and the inhospital mortality rate was not significantly different. The proportion of hospital costs incurred by intensive care unit care was 7.8% in low, 19.8% in medium and 28.2% in high (P<0.001) admission hospitals. The potential cost savings of altering intensive care unit utilisation practices for patients with heart failure was CAN$234.8m over the study period. CONCLUSIONS: In a national cohort of patients hospitalised with heart failure, we observed that low intensive care unit utilisation centres had lower hospital costs with no differences in mortality rates. The development of standardised admission criteria for high-cost and high acuity intensive care unit beds could reduce costs to the healthcare system.

17.
Clin Chem ; 65(6): 781-790, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30988169

RESUMO

BACKGROUND: Cardiac and renal diseases commonly occur with bidirectional interactions. We hypothesized that cardiac and inflammatory biomarkers may assist in identification of patients with type 2 diabetes mellitus (T2DM) at high risk of worsening renal function. METHODS: In this exploratory analysis from SAVOR-TIMI 53, concentrations of high-sensitivity cardiac troponin T (hs-TnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and high-sensitivity C-reactive protein (hs-CRP) were measured in baseline serum samples of 12310 patients. The primary end point for this analysis was a ≥40% decrease in estimated glomerular filtration rate (eGFR) at end of treatment (EOT) at a median of 2.1 years. The relationships between biomarkers and the end point were modeled using adjusted logistic and Cox regression. RESULTS: After multivariable adjustment including baseline renal function, each biomarker was independently associated with an increased risk of ≥40% decrease in eGFR at EOT [Quartile (Q) Q4 vs Q1: hs-TnT adjusted odds ratio (OR), 5.63 (3.49-9.10); NT-proBNP adjusted OR, 3.53 (2.29-5.45); hs-CRP adjusted OR, 1.84 (95% CI, 1.27-2.68); all P values ≤0.001]. Furthermore, each biomarker was independently associated with higher risk of worsening of urinary albumin-to-creatinine ratio (UACR) category (all P values ≤0.002). Sensitivity analyses in patients without heart failure and eGFR >60 mL/min provided similar results. In an adjusted multimarker model, hs-TnT and NT-proBNP remained significantly associated with both renal outcomes (all P values <0.01). CONCLUSIONS: hs-TnT, NT-proBNP, and hs-CRP were each associated with worsening of renal function [reduction in eGFR (≥40%) and deterioration in UACR class] in high-risk patients with T2DM. Patients with high cardiac or inflammatory biomarkers should be treated not only for their risk of cardiovascular outcomes but also followed for renal deterioration.

18.
Circ Cardiovasc Qual Outcomes ; 12(3): e005618, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30879324

RESUMO

Background Clinical investigations of shock in cardiac intensive care units (CICUs) have primarily focused on acute myocardial infarction (AMI) complicated by cardiogenic shock (AMICS). Few studies have evaluated the full spectrum of shock in contemporary CICUs. Methods and Results The Critical Care Cardiology Trials Network is a multicenter network of advanced CICUs in North America. Anytime between September 2017 and September 2018, each center (n=16) contributed a 2-month snap-shot of all consecutive medical admissions to the CICU. Data were submitted to the central coordinating center (TIMI Study Group, Boston, MA). Shock was defined as sustained systolic blood pressure <90 mm Hg with end-organ dysfunction ascribed to the hypotension. Shock type was classified by site investigators as cardiogenic, distributive, hypovolemic, or mixed. Among 3049 CICU admissions, 677 (22%) met clinical criteria for shock. Shock type was varied, with 66% assessed as cardiogenic shock (CS), 7% as distributive, 3% as hypovolemic, 20% as mixed, and 4% as unknown. Among patients with CS (n=450), 30% had AMICS, 18% had ischemic cardiomyopathy without AMI, 28% had nonischemic cardiomyopathy, and 17% had a cardiac cause other than primary myocardial dysfunction. Patients with mixed shock had cardiovascular comorbidities similar to patients with CS. The median CICU stay was 4.0 days (interquartile range [IQR], 2.5-8.1 days) for AMICS, 4.3 days (IQR, 2.1-8.5 days) for CS not related to AMI, and 5.8 days (IQR, 2.9-10.0 days) for mixed shock versus 1.9 days (IQR, 1.0-3.6) for patients without shock ( P<0.01 for each). Median Sequential Organ Failure Assessment scores were higher in patients with mixed shock (10; IQR, 6-13) versus AMICS (8; IQR, 5-11) or CS without AMI (7; IQR, 5-11; each P<0.01). In-hospital mortality rates were 36% (95% CI, 28%-45%), 31% (95% CI, 26%-36%), and 39% (95% CI, 31%-48%) in AMICS, CS without AMI, and mixed shock, respectively. Conclusions The epidemiology of shock in contemporary advanced CICUs is varied, and AMICS now represents less than one-third of all CS. Despite advanced therapies, mortality in CS and mixed shock remains high. Investigation of management strategies and new therapies to treat shock in the CICU should take this epidemiology into account.

19.
J Am Heart Assoc ; 8(6): e011721, 2019 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-30879373

RESUMO

Background Cardiovascular intensive care units ( CICUs ) have evolved from coronary care wards into distinct units for critically ill patients with primary cardiac diseases, often suffering from illnesses that cross multiple disciplines. Mounting evidence has demonstrated improved survival with the incorporation of dedicated CICU providers with expertise in critical care medicine ( CCM ). This is the first study to systematically survey dual certified physicians in order to assess the relevance of CCM training to contemporary CICU care. Methods and Results Utilizing American Board of Internal Medicine data through 2014, 397 eligible physicians had obtained initial certification in both cardiovascular disease and CCM . A survey to delineate the role of critical care training in the CICU was provided to these physicians. Among those surveyed, 120 physicians (30%) responded. Dual certified physicians reported frequent use of their CCM skills in the CICU , highlighting ventilator management, multiorgan dysfunction management, end-of-life care, and airway management. The majority (85%) cited these skills as the reason CCM training should be prioritized by future CICU providers. Few (17%) agreed that general cardiology fellowship alone is currently sufficient to care for patients in the modern CICU . Furthermore, there was a consensus that there is an unmet need for cardiologists trained in CCM (70%) and that CICU s should adopt a level system similar to trauma centers (61%). Conclusions Citing specific skills acquired during CCM training, dual certified critical care cardiologists reported that their additional critical care experience was necessary in their practice to effectively deliver care in the modern CICU .

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