Sepsis is the life-threatening organ dysfunction caused by a dysregulated host response to infection and is the leading cause of death in intensive care units. Cardiac dysfunction caused by sepsis, ...usually termed sepsis-induced cardiomyopathy, is common and has long been a subject of interest. In this Review, we explore the definition, epidemiology, diagnosis and pathophysiology of septic cardiomyopathy, with an emphasis on how best to interpret this condition in the clinical context. Advances in diagnostic techniques have increased the sensitivity of detection of myocardial abnormalities but have posed challenges in linking those abnormalities to therapeutic strategies and relevant clinical outcomes. Sophisticated methodologies have elucidated various pathophysiological mechanisms but the extent to which these are adaptive responses is yet to be definitively answered. Although the indications for monitoring and treating septic cardiomyopathy are clinical and directed towards restoring tissue perfusion, a better understanding of the course and implications of septic cardiomyopathy can help to optimize interventions and improve clinical outcomes.
Vasoactive drugs in circulatory shock Hollenberg, Steven M
American journal of respiratory and critical care medicine,
04/2011, Volume:
183, Issue:
7
Journal Article
Peer reviewed
Shock occurs when failure of the cardiovascular system compromises tissue perfusion. When fluid administration fails to restore adequate arterial pressure and organ perfusion in patients with shock, ...therapy with vasoactive agents should be initiated. The key to selecting among vasoactive agents is to make the choice in the context of the goals of therapy. The ultimate goals of hemodynamic therapy in shock are to restore effective tissue perfusion and to normalize cellular metabolism. The clinician needs to consider ways of achieving those goals and the mechanisms of action of potential therapies. Armed with this knowledge, it becomes easier to match the mechanism of action of a particular agent to the goals of therapy. When this is done, differences among various agents are seen primarily as differences in mechanisms of action, and discussions about which agent is "best" are transformed into consideration of which agent is best suited to implement the therapeutic strategy that has been selected in a given clinical context. Despite the complex pathophysiology of shock, use of vasoactive agents for hemodynamic support of patients with shock can be guided by an underlying approach in which clinicians define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis.
This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.
A ...comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Raters Gonna Rate Hollenberg, Steven M.; Contreras, Johanna
The American journal of cardiology,
09/2023, Volume:
203
Journal Article
Peer reviewed
Potential limitations to robust guidelines include gaps and/or weaknesses in the scientific evidence base, potential conflicts of interest in groups developing guidelines and members of guideline ...formulation committees, lack of editorial independence, and incomplete consideration of applicability given the diversity of the population at risk and perspectives of patients.2 With the recognition that the potential benefits of practice guidelines are only as good as the quality of the guidelines themselves, a multidisciplinary international panel supported by the Canadian Institutes of Health Research formulated the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument in 2003.3 This instrument was updated in 2010 to the AGREE II tool.4 AGREE II organizes evaluation of guidelines into 23 items targeting various aspects of practice guideline quality within 6 domains using a 7-point scale: In the previous issue of the American Journal of Cardiology, Sephien et al5 have applied the AGREE II methodology to 6 clinical practice guidelines on heart failure published within the past 2 years, from 4 continents: the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America Guideline for the Management of Heart Failure, the 2021 European Society of Cardiology Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure, the 2021 update of the Brazilian Heart Failure Guideline, the Canadian Cardiovascular Society Heart Failure Guidelines update in 2021, the Japan Cardiovascular Society 2021 Guideline on Implantable Left Ventricular Assist Device for Patients With Advanced Heart Failure, and the Japan Cardiovascular Society 2021 Guideline Focused Update on Diagnosis and Treatment of Acute and Chronic Heart Failure.5 The methodological quality assessment done by the authors varied across the 6 AGREE II domains. ...a guideline is only useful to the extent that it improves the quality of patient care.
The outcome of cardiogenic shock complicating myocardial infarction has not appreciably changed in the last 30 years despite the development of various percutaneous mechanical circulatory support ...options. It is clear that there are varying degrees of cardiogenic shock but there is no robust classification scheme to categorize this disease state.
A multidisciplinary group of experts convened by the Society for Cardiovascular Angiography and Interventions was assembled to derive a proposed classification schema for cardiogenic shock. Representatives from cardiology (interventional, advanced heart failure, noninvasive), emergency medicine, critical care, and cardiac nursing all collaborated to develop the proposed schema.
A system describing stages of cardiogenic shock from A to E was developed. Stage A is "at risk" for cardiogenic shock, stage B is "beginning" shock, stage C is "classic" cardiogenic shock, stage D is "deteriorating", and E is "extremis". The difference between stages B and C is the presence of hypoperfusion which is present in stages C and higher. Stage D implies that the initial set of interventions chosen have not restored stability and adequate perfusion despite at least 30 minutes of observation and stage E is the patient in extremis, highly unstable, often with cardiovascular collapse.
This proposed classification system is simple, clinically applicable across the care spectrum from pre-hospital providers to intensive care staff but will require future validation studies to assess its utility and potential prognostic implications.
2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Levine, Glenn N., MD, FACC, FAHA; Bates, Eric R., MD, FACC, FAHA; Blankenship, James C., MD, FACC, FSCAI ...
Journal of the American College of Cardiology,
12/2011, Volume:
58, Issue:
24
Journal Article
To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012."
A consensus committee of 55 international experts representing 25 international ...organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.
The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.
The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions.
Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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