Background
Patients with concomitant cardiac arrest (CA) and shock are at increased risk of mortality, even when stratified according to shock severity. We sought to determine whether the presence of ...ventricular fibrillation (VF) modified the relationship between CA and mortality in cardiac intensive care unit (CICU) patients.
Methods
We retrospectively analyzed unique Mayo Clinic CICU patients admitted between 2007 and 2015. Society for Cardiovascular Angiography and Intervention (SCAI) shock stages A through E were classified at admission. Hospital mortality in each SCAI shock stage was stratified by the presence of CA, VF CA, or non‐VF CA.
Results
We included 9,898 patients with a mean age of 68 years (38% females). CA was present in 12%, including 53% with VF CA and 47% with non‐VF CA. Hospital mortality was higher in patients with CA compared to patients without CA (34% vs. 6%; adjusted odds ratio OR = 3.1, 95% CI 2.4, 4.0, p < .001), and patients with non‐VF CA had higher hospital mortality than patients with VF CA (44% vs. 25%; adjusted OR = 2.1, 95% CI 1.4, 3.0, p < .001). After adjustment, patients with any CA or non‐VF CA had higher hospital mortality at each SCAI stage, except stage E (all other p < .05), whereas patients with VF CA did not (all p > .1).
Conclusions
CA rhythm modifies the relationship between CA and mortality in CICU patients, when accounting for coma, shock, and organ failure. Outcome studies examining CA in patients with cardiogenic shock need to account for important differences such as CA rhythm.
Key Points
Initial serum lactate and lactate clearance in resuscitated cardiac arrests have been consistently associated with survival.
The current study extends this association to a subset of ...cardiac arrest patients selected to undergo urgent cardiac catheterization.
We suggest that future risk stratification studies could focus on the development of dynamic risk prediction models that incorporate clinical variables throughout the cardiac arrest chain‐of‐care.
•Many patients with shock have sustained significant end-organ or neurologic injury by the time of first medical contact or transfer to a cardiogenic shock center.•The extent of end-organ or ...neurologic injury sustained prior to mechanical support may ultimately play a significant role in determining long-term exit strategies for patients with cardiogenic shock.•The challenges inherent in accounting for this injury and its downstream sequelae represent a persistent source of type II error in cardiogenic-shock trials and a challenge for the CICU clinician at the bedside.
Levosimendan is an inotropic agent that has been shown in small studies to prevent or treat the low cardiac output syndrome after cardiac surgery.
In a multicenter, randomized, placebo-controlled, ...phase 3 trial, we evaluated the efficacy and safety of levosimendan in patients with a left ventricular ejection fraction of 35% or less who were undergoing cardiac surgery with the use of cardiopulmonary bypass. Patients were randomly assigned to receive either intravenous levosimendan (at a dose of 0.2 μg per kilogram of body weight per minute for 1 hour, followed by a dose of 0.1 μg per kilogram per minute for 23 hours) or placebo, with the infusion started before surgery. The two primary end points were a four-component composite of death through day 30, renal-replacement therapy through day 30, perioperative myocardial infarction through day 5, or use of a mechanical cardiac assist device through day 5; and a two-component composite of death through day 30 or use of a mechanical cardiac assist device through day 5.
A total of 882 patients underwent randomization, 849 of whom received levosimendan or placebo and were included in the modified intention-to-treat population. The four-component primary end point occurred in 105 of 428 patients (24.5%) assigned to receive levosimendan and in 103 of 421 (24.5%) assigned to receive placebo (adjusted odds ratio, 1.00; 99% confidence interval CI, 0.66 to 1.54; P=0.98). The two-component primary end point occurred in 56 patients (13.1%) assigned to receive levosimendan and in 48 (11.4%) assigned to receive placebo (adjusted odds ratio, 1.18; 96% CI, 0.76 to 1.82; P=0.45). The rate of adverse events did not differ significantly between the two groups.
Prophylactic levosimendan did not result in a rate of the short-term composite end point of death, renal-replacement therapy, perioperative myocardial infarction, or use of a mechanical cardiac assist device that was lower than the rate with placebo among patients with a reduced left ventricular ejection fraction who were undergoing cardiac surgery with the use of cardiopulmonary bypass. (Funded by Tenax Therapeutics; LEVO-CTS ClinicalTrials.gov number, NCT02025621 .).
New Findings
What is the central question of this study?
Is the amount of inhaled nitric oxide (NO) used during a diffusing capacity for inhaled NO manoeuvre sufficient to reduce pulmonary artery ...systolic pressure (PASP)?
What is the main finding and its importance?
These findings suggest that a single breath of inhaled NO does not change PASP, and combined with previous correlational work, further validates the use of the diffusing capacity for NO manoeuvre as a technique to determine pulmonary capillary blood volume and membrane diffusing capacity.
The measurement of diffusing capacity is an important pulmonary function test to evaluate gas exchange. Using both carbon monoxide and nitric oxide (NO), the diffusing capacity for nitric oxide (DL,NO) technique allows for the partitioning of capillary blood volume and membrane diffusing capacity. However, inhaled NO is known to dilate pulmonary arterioles in both health and disease and therefore could alter the outcomes that the DL,NO technique aims to quantify. The purpose of the study was to determine if a DL,NO manoeuvre alters pulmonary perfusion pressure. Nine participants completed 12 simulated 10‐s breath‐hold DL,NO manoeuvres (n = 6 placebo inhalations and n = 6 with 40 ppm NO; order randomized) during which tricuspid regurgitant jet velocity was recorded continuously using Doppler ultrasound to estimate pulmonary artery systolic pressure (PASP) as a surrogate for pulmonary perfusion pressure. The PASP was not different between the placebo and NO conditions (P = 0.742). These data indicate that a single DL,NO manoeuvre does not alter PASP and therefore would not be expected to acutely alter pulmonary capillary blood volume or membrane diffusing capacity.
Cardiogenic shock (CS) portends high morbidity and mortality in the contemporary era. Despite advances in temporary mechanical circulatory supports (MCS), their routine use in CS to improve outcomes ...has not been established. Delays in diagnosis and timely delivery of care, disparities in accessing adjunct therapies such revascularization or MCS, and lack of a systematic approach to care of CS contribute to the poor outcomes observed in CS patients. There is growing interest for developing a standardized multidisciplinary team‐based approach in the management of CS. Recent prospective studies have shown feasibility of CS teams in improving survival across a spectrum of CS presentations. Herein, we will review the rationale for CS teams focusing on evidence supporting its use in streamlining care, optimizing revascularization strategies, and patient identification and MCS selection. The proposed structure and flow of CS teams will be outlined. An in‐depth analysis of four recent studies demonstrating improved outcomes with CS teams is presented. Finally, we will explore potential implementation hurdles and future directions in refining and widespread implementation of dedicated cross‐specialty CS teams.
We describe variables and outcomes associated with peri-operative mechanical circulatory support (MCS) utilization among patients enrolled in the Levosimendan in patients with Left Ventricular ...Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial.
In the LEVO-CTS trial, MCS utilization (defined as intra-aortic balloon pump, extracorporeal membrane oxygenation, or surgical ventricular assist device) within 5 days of surgery was examined. The association between MCS use and outcomes including 90-day mortality, 30-day renal-replacement therapy, and hospital and critical stay length of stay were determined.
Among the 849 patients from 70 centers randomized to levosimendan or placebo, 85 (10.0%) patients were treated with MCS (71 intra-aortic balloon pump, 7 extracorporeal membrane oxygenation, 7 ventricular assist device); with 89.4% started on post-operative day 0. Inter-institutional use ranged from 0% to 100%. Variables independently associated with MCS utilization included combined coronary artery bypass grafting and valve surgery (adjusted odds ratio OR 2.73, 95% confidence interval CI 1.70-4.37, P < .001), history of lung disease (OR 1.70, 95% CI 1.06-2.70, P = .029), and history of heart failure (OR 2.44, 95% CI 1.10-5.45, P = .027). Adjusted 90-day mortality (22.4% vs 4.1%, hazard ratio 6.11, 95% CI 3.95-9.44, P < .001) was higher, and median critical care length of stay (8.0 vs 4.0 days, P < .001) was longer in patients managed with MCS.
In a randomized controlled trial of high-risk cardiac surgical patients in North America, we observed patient, and surgical variables associated with MCS utilization. MCS use was associated with a higher risk of post-operative mortality.
A new 5-stage cardiogenic shock (CS) classification scheme was recently proposed by the Society for Cardiovascular Angiography and Intervention (SCAI) for the purpose of risk stratification.
This ...study sought to apply the SCAI shock classification in a cardiac intensive care unit (CICU) population.
The study retrospectively analyzed Mayo Clinic CICU patients admitted between 2007 and 2015. SCAI CS stages A through E were classified retrospectively using CICU admission data based on the presence of hypotension or tachycardia, hypoperfusion, deterioration, and refractory shock. Hospital mortality in each SCAI shock stage was stratified by cardiac arrest (CA).
Among the 10,004 unique patients, 43.1% had acute coronary syndrome, 46.1% had heart failure, and 12.1% had CA. The proportion of patients in SCAI CS stages A through E was 46.0%, 30.0%, 15.7%, 7.3%, and 1.0% and unadjusted hospital mortality in these stages was 3.0%, 7.1%, 12.4%, 40.4%, and 67.0% (p < 0.001), respectively. After multivariable adjustment, each higher SCAI shock stage was associated with increased hospital mortality (adjusted odds ratio: 1.53 to 6.80; all p < 0.001) compared with SCAI shock stage A, as was CA (adjusted odds ratio: 3.99; 95% confidence interval: 3.27 to 4.86; p < 0.001). Results were consistent in the subset of patients with acute coronary syndrome or heart failure.
When assessed at the time of CICU admission, the SCAI CS classification, including presence or absence of CA, provided robust hospital mortality risk stratification. This classification system could be implemented as a clinical and research tool to identify, communicate, and predict the risk of death in patients with, and at risk for, CS.
Display omitted
PDF
