Getting cardiogenic shock patients to the right place-How initial intensive care unit triage decisions impact processes of care and outcomes.

The objective of this study was to determine how initial intensive care unit triage decisions impact processes of care and outcomes for emergency department patients hospitalized with cardiogenic shock. Individuals with cardiogenic shock were stratified based upon whether they were initially admitted to a cardiac versus noncardiovascular intensive care setting. Those initially triaged to a noncardiovascular intensive care unit were less likely to receive potentially life-saving interventions, including percutaneous coronary intervention and temporary mechanical circulatory support, and were more likely to see significant delays in these interventions if ultimately used. Additionally, admitting cardiogenic shock patients to noncardiovascular intensive care units may result in worse survival. These findings underscore the importance of appropriate identification and triage of emergency department patients with cardiogenic shock-a potentially critical contribution of contemporary cardiogenic shock teams.

Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit.

BACKGROUND: Delirium is common in the medical and surgical intensive care unit (ICU), and its association with morbidity and mortality is well described. Despite emerging data, which have highlighted a growing critical care burden in the contemporary cardiac ICU (CICU), much less is known about delirium in this specialized setting. METHODS AND RESULTS: Records for consecutive CICU patients aged ≥18 years who were admitted to our academic, tertiary care institution from December 2012 to March 2014 for a primary cardiovascular diagnosis were reviewed. Only those with a documented Confusion Assessment Method for ICU score were included in the final analysis. Baseline characteristics, resource use, and outcomes were collected. Disease severity was assessed using the modified Acute Physiology and Chronic Health Evaluation II score and the Simplified Acute Physiology ScoreII. Multivariable logistic and linear regression models were constructed to evaluate the association between CICU delirium, length of stay, and death. Among 590 patients included, the prevalence of CICU delirium was 20.3%. Delirious patients were older, had greater disease severity, required longer ICU stays (5 vs 2 days; P < .001), and had higher mortality (27% vs 3%; P < .001). In the adjusted setting, delirium remained strongly associated with both increased mortality (P < .001) and length of stay (P = .001). CONCLUSIONS: In those with cardiac critical illness, delirium is common and associated with worse survival and greater resource consumption. Future study is needed to validate these findings and to develop effective strategies for the early identification and treatment of the delirious CICU patient.

Patients with Left Ventricular Thrombus Despite Normal Systolic Function.

The formation of a thrombus in the left ventricle (LV) in patients with normal systolic function is very rare. We report a case and identified 31 other adult patients who had an LV thrombus with normal LV systolic function. The median (IQR) age of these patients was 43 [37,59] years with a slight male predominance (59%). The vast majority of patients presented with embolic complications (28; 88%) with 3 of the other patients presenting with a febrile illness. Most of the cases occurred in the setting of an identifiable medical condition that carries an increased risk of thrombosis including inflammatory diseases, malignancies or hypereosinophilia. Treatment generally included anticoagulation with or without surgical removal or systemic thrombolysis. Recurrence of LV thrombus and/or embolic events have been reported in patients with LV thrombus and normal LV systolic function suggesting that long term anticoagulation may be needed.

Fibrinogen Levels and Bleeding Risk in Patients Undergoing Ultrasound-Assisted Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism.

OBJECTIVES: We sought to test the hypothesis that patients undergoing ultrasound-assisted catheter-directed thrombolysis (USAT) with standard alteplase and heparin dosing would not develop significant depletion of systemic fibrinogen, which may account for the lower risk of bleeding seen in contemporary trials. We also sought to compare the relative outcomes of individuals with submassive pulmonary embolism (PE) undergoing USAT and anticoagulation alone. METHODS: Utilizing a single-center prospective registry, we identified 102 consecutive adult patients with submassive PE who were considered for USAT based on a standardized treatment algorithm between November 2016 and May 2019. Patients not receiving USAT therapy were treated with anticoagulation alone. RESULTS: Baseline characteristics were generally similar between groups (n = 51 in each group). Major bleeding rates were not significantly different between groups (2.0% vs 5.9% in USAT vs control, respectively; P=.62). Notably, no USAT patient experienced clinically significant hypofibrinogenemia (mean trough fibrinogen, 369.8 ± 127.1 mg/dL; minimum, 187 mg/dL). The mean trough fibrinogen of patients experiencing any bleeding event (major or minor) was 306.6 mg/dL (SE, 23.9 mg/dL) vs 380.3 mg/dL (SE, 20.4 mg/dL) in those without a bleeding event (P=.02). CONCLUSIONS: In this cohort analysis of patients undergoing USAT, there was no evidence for clinically significant depletion of fibrinogen or intracranial hemorrhage. Although our data suggest an association between lower fibrinogen levels and bleeding events, our results are not clear enough to suggest a clinically useful fibrinogen cut-off value. Further study is needed to determine the utility of routine fibrinogen monitoring in this population.

Left Ventricular Thrombus Formation in the Setting of Normal Systolic Function.

We describe the case of a 42-year-old female with recurrent left ventricular (LV) thrombus and multiple embolic events despite having normal LV systolic function. The clinical presentation, associated conditions, diagnostic evaluation and treatment of patients with LV thrombus in the setting of normal LV systolic function are discussed. (Level of Difficulty: Beginner.).

Age-Stratified National Trends in Pulmonary Embolism Admissions.

BACKGROUND: Pulmonary embolism (PE) is one of the leading causes of death in hospitalized patients. Treatment patterns and patient demographics for PE are changing; therefore, we sought to evaluate national trends in admission rate, discharge disposition, and length of stay (LOS) in patients hospitalized with PE. METHODS: The National Inpatient Sample database was used to collect data for hospitalizations of patients ≥ 20 years old with primary diagnosis of PE between January 2000 and September 2015. Patient demographics and hospital characteristics, stratified by patient age, were reported. Trends in rates of hospitalizations for PE, LOS, discharge disposition, and hospital charges were assessed across age groups. RESULTS: There were an estimated 2,159,568 hospitalizations with primary diagnosis of PE. The rate of PE per 100,000 persons increased by > 100%, and was highest among elderly patients. Increased age and comorbidity burden were independently associated with poor outcomes. Inpatient mortality and LOS decreased across all age groups, but was highest in the elderly. Home health utilization increased in patients ≥ 55 years old. Average hospital charges increased across all age groups, despite shorter length of stay, with patients ≥ 85 experiencing $13,000 average increase. CONCLUSIONS: Between 2000 and 2015, the rate of hospitalization for PE increased across all age groups. Despite improvements in average LOS and inpatient mortality, hospitalizations became more expensive, and patients required more resources (ie, home health) on discharge. This increased resource utilization was most apparent in elderly patients. This suggests that targeted clinical trials designed to improve outcomes in all age brackets are needed.

Mechanisms of ST Elevation Myocardial Infarction in Patients Hospitalized for Noncardiac Conditions.

ST elevation myocardial infarction (STEMI) occurring in patients hospitalized for a noncardiac condition is associated with a high mortality rate and thus we sought to determine the mechanisms underlying STEMI in this patient population. This is a single center retrospective study of 70 patients who had STEMI while hospitalized on a noncardiac service and underwent coronary angiography. Thrombotic in-hospital STEMI was defined by angiographic or intravascular imaging evidence of intracoronary thrombus, plaque rupture, or stent thrombosis. Thirty-six (51%) inpatient STEMIs developed in the operating room or various postoperative stages and 6 (9%) after endoscopy or a percutaneous procedure. Thrombotic etiologies were found in 39 (56%) patients. Nonthrombotic etiologies included vasospasm, supply-demand mismatch, and takotsubo cardiomyopathy. Patients in the thrombotic group were more likely to have antiplatelet medications discontinued on admission, had higher peak troponin levels and were more likely to undergo percutaneous coronary intervention than patients in the nonthrombotic group. Exposure to vasopressors, time from ECG to angiography, post-STEMI ejection fraction, length of stay, and in-hospital mortality were similar in both groups. There was no difference in the use of percutaneous coronary intervention in patients but longer ECG to coronary angiography times and fivefold higher in-hospital mortality in thrombotic inpatient STEMI compared with 643 patients who presented with an out-of-hospital STEMI during the same time period. In conclusion, thrombotic and nonthrombotic mechanisms cause STEMI in hospitalized patients and are associated with a high mortality.

Length of Stay, Mortality, Cost, and Perceptions of Care Associated With Transition From an Open to Closed Staffing Model in the Cardiac Intensive Care Unit.

BACKGROUND: Organizational models in the intensive care unit (ICU) have classically been described as either closed or open, depending on the presence or absence of a dedicated ICU team. Although a closed model has been shown to improve patient outcomes in medical and surgical ICUs, the merits of various care models have not been previously explored in the cardiac ICU (CICU) setting. METHODS: From November 2012 to March 2014, data were prospectively collected on all admissions before and after transition from an open to closed CICU at our institution. Baseline clinical variables, illness severity, admission and discharge diagnoses, resource use, and outcomes were recorded. Anonymous surveys were also collected from nursing and resident trainee participants to evaluate the influence of unit structure on perceptions of care. Descriptive statistics were used, and logistic regression modeling was performed to examine the impact of unit structure on mortality. RESULTS: The study consisted of 670 patients, 332 (49.6%) of whom were admitted to the open CICU model and 338 (50.4%) of whom were admitted to the closed model. Neither CICU nor hospital mortality differed between the open and closed units, though length of stay was shorter in the closed CICU. Additionally, nurses and resident trainees reported that the closed CICU allowed for better communication, collaboration, and education. CONCLUSIONS: Although there was no significant impact of unit structure on patient outcomes in this single-center study, the closed CICU model was associated with better perceptions of care.