Cardiac Intensive Care Unit Admission Research Articles

Exposure to hyperoxemia and mortality in cardiac intensive care unit patients

Abstract Funding Acknowledgements None. Background Hyperoxemia (a high PaO2, i.e. >200-300 mmHg) has been associated with adverse outcomes in general critical care settings as well as in acute cardiovascular care conditions. The association between hyperoxemia and mortality has not been characterized in the heterogeneous population admitted to the cardiac intensive care unit (CICU). We aimed to examine the association between hyperoxemia on CICU admission with in-hospital mortality. Methods We retrospectively analyzed Mayo Clinic CICU patients from January 2007 to April 2018. PaO2 closest on admission was analyzed as a continuous variable (per 100 mmHg) and categorized as: 60-100 mmHg (51.9%), 101-150 mmHg (28.6%), 151-200 mmHg (10.6%), 201-300 mmHg (6.4%), and >300 mmHg (2.5%). Those without PaO2 on admission and those with hypoxemia were excluded. The primary outcome was all-cause in-hospital mortality evaluated using logistic regression, after adjusting for age, Charlson Comorbidity Index, M-CARS, and use of IMV and NIPPV. Results A total of 3,368 patients were included (median 70.3 years, 39.4% women). Admission diagnoses included ACS (37.0%, with 19.8% STEMI), HF (67.8%), shock (33.0%) and cardiac arrest (25.3%). Median admission PaO2 was 99 (IQR 78, 136) mmHg, with no difference in median PaO2 between hospital survivors and inpatient deaths (99 versus 98, p = 0.38). A J-shaped relationship was observed between admission PaO2 and in-hospital mortality (Figure A), with slightly higher mortality below 100 mmHg and incrementally higher mortality above this threshold (esp. at >200 mmHg). The incremental association between higher PaO2 and mortality (adjusted OR 1.17 per 100 mmHg higher, 95% CI 1.01-1.34, P = 0.03) was focused in the highest PaO2 group (i.e., >300 mmHg; Figure B). Conclusion Hyperoxia (esp. PaO2 >300 mmHg) on CICU admission is associated with increased in-hospital mortality, demonstrating a J-shaped association with an inflection point of lowest mortality around 100 mmHg. Further studies are warranted to assess if specific oxygen targets influence outcomes in critically ill cardiac patients.

Higher mortality among off-hours versus regular-hours admissions to the cardiac intensive care unit (CICU): insights from the critical care cardiology trials network registry (CCCTN)

Abstract Funding Acknowledgements None. Background The outcomes of patients admitted to general intensive care units vary significantly according to the time of admission. Whether this applies to the CICU setting is unknown. Purpose We sought to determine if patient characteristics, admission source, critical care therapy utilization, and clinical outcomes differ according to whether CICU admission occurred during regular-hours or off-hours. Methods CCCTN is a multicenter prospective registry of consecutive admissions to CICUs in North America coordinated by the TIMI Study Group. For this analysis of admissions during calendar year 2022, "regular-hours" was defined as 7 a.m.- 7 p.m. Monday-Friday, and "off-hours" was defined as 7 p.m.- 7 a.m. on weekdays or at any time on Saturday or Sunday. Logistic regression analysis was used to adjust in-hospital mortality rates for admission time (on-hours vs. off-hours), age, sex, SOFA score, and cardiac arrest. Results Among 5238 CICU admissions, 2956 (56.4%) occurred during off-hours. Patient demographics (mean age: 67.0 years, 35.7% female, 51.1% white) and comorbidities were generally similar among off-hours and regular-hours admissions. The median SOFA score was 3.0 in both groups. Compared to regular-hours admissions, off-hours admissions were more likely to originate from the ED (39.9% vs. 29.4%, p<0.0001) and less likely to originate from a procedural area (24.5% vs. 41.8%, p<0.0001). ST-elevation MI was a more common admission diagnosis among off-hours vs. regular-hours admissions (19.2% vs. 16.4%, p=0.009). Primary CICU indications of respiratory insufficiency, unstable arrhythmia, cardiac arrest, and distributive/mixed shock were more common among off-hours admissions (Table). Mechanical ventilation, IV vasoactive therapy, and targeted temperature management (TTM) were utilized more frequently among patients admitted during off-hours. Median ICU (2.5 vs. 2.0d) and hospital length of stay (6.2 vs. 5.8d) were longer for off-hours admissions (both p<0.0001). Crude CICU mortality (11.4% vs. 8.5%, p=0.0005) and in-hospital mortality (15.6% vs. 11.7%, p<0.0001) were significantly higher among off-hours admissions (Figure). After adjustment, off-hours admission remained significantly associated with higher in-hospital mortality (OR 1.2, 95% CI 1.02 – 1.49, p=0.03). Conclusions Off-hours and regular-hours admissions to the CICU had similar baseline characteristics but differed significantly regarding source of admission, indication for admission, and utilization of critical care therapies. These differences were associated with worse clinical outcomes among off-hours admissions, which may suggest the need for more intensive staffing in CICUs during these times.FigureTable

Global longitudinal strain as a predictor of mortality in patients with cardiogenic shock

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Aarhus University Dagmar Marshalls Fond. Background The assessment of left ventricular (LV) function through transthoracic echocardiography (TTE) is essential for guiding diagnosis and treatment in cases of cardiogenic shock (CS). Myocardial global longitudinal strain (GLS) provides an objective and reproducible measure of systolic function, independently predicting outcomes in acute heart failure, regardless of left ventricular ejection fraction (LVEF). However, whether assessment of GLS can predict mortality in patients with CS remains unknown. Purpose In this study, we aimed to evaluate the prognostic significance of GLS in patients with CS. Methods Data from cardiac intensive care unit (CICU) patients admitted between 2007 and 2018 with CS who received vasoactive agents and/or mechanical circulatory support were analysed. GLS (as absolute values) and biplane LVEF were measured via TTE performed within 24 hours of CICU admission. Patients with CS were categorised based on the GLS quartile: mild (GLS >9.7%), moderate (7.0% < GLS <9.6%), severe (5.0% < GLS < 6.9%), and very severe (GLS ≤ 4.9%). CICU and in-hospital mortality were compared across GLS categories, and the relationship between GLS and mortality was assessed using multivariable logistic regression. Results The study included 626 patients with a median age of 68.6 years, a median LVEF of 31% (IQR 24 to 40%), and a median GLS of 7.0% (IQR 5.0 to 9.7%). In-hospital mortality was 29.1%. As GLS deteriorated, there was an increasing need for vasopressors (P<0.001). Patients with progressively lower GLS exhibited significantly higher CICU and in-hospital mortality across the GLS quartiles (Figure A; P<0.001). Patients in the severe (adjusted OR 2.67; p<0.001) and very severe category (adjusted OR 3.54; P<0.001) had significantly increased risk of in-hospital death compared with mild category. In multivariable analysis, every 1% decrease in GLS corresponded to a 14% higher risk of in-hospital mortality (P<0.001). Finally, GLS outperformed LVEF for discrimination of in-hospital mortality (P=0.002), and when both measurements were included in the same multivariable model, only GLS remained significant. When patients were divided according to whether they had GLS and/or LVEF below the median value, patients with low GLS had higher mortality irrespective of the LVEF (Figure B). Conclusion In patients with CS, GLS assessment surpasses LVEF in its prognostic value and improves risk stratification. Routine evaluation of GLS should be considered for patients with CS.Figure AFigure B

Frailty in the Cardiac Intensive Care Unit: Assessment and Impact.

Frailty, a clinical syndrome of increased vulnerability, due to diminished cognitive, physical, and physiological reserves is a growing concern in the cardiac intensive care unit (CICU). It contributes to morbidity, mortality, and complications and often exerts a bidirectional association with cardiovascular disease. Althought it predominately affects older adults, frailty can also be observed in younger patients less than 65 years of age, with approximately 30% of those admitted CICU are frail. Acute cardiovascular illness can also impair physical and cognitive functioning among survivors and these survivors often suffer from frailty and functional declines post-CICU discharge. Patients with frailty in the CICU often have higher comorbidity burden and they are less likely to receive optimal therapy for their acute cardiovascular conditions. Given the significance of this geriatric syndrome, this review will focus on assessment, clinical outcomes, and interventions, in an attempt to establish appropriate assessment, management, and resource utilization in frail patients during and after CICU admission.

Development and external validation of a dynamic risk score for early prediction of cardiogenic shock in cardiac intensive care units using machine learning.

Myocardial infarction and heart failure are major cardiovascular diseases that affect millions of people in the US with the morbidity and mortality being highest among patients who develop cardiogenic shock. Early recognition of cardiogenic shock allows prompt implementation of treatment measures. Our objective is to develop a new dynamic risk score, called CShock, to improve early detection of cardiogenic shock in cardiac intensive care unit (ICU). We developed and externally validated a deep learning-based risk stratification tool, called CShock, for patients admitted into the cardiac ICU with acute decompensated heart failure and/or myocardial infarction to predict onset of cardiogenic shock. We prepared a cardiac ICU dataset using MIMIC-III database by annotating with physician adjudicated outcomes. This dataset that consisted of 1500 patients with 204 having cardiogenic/mixed shock was then used to train CShock. The features used to train the model for CShock included patient demographics, cardiac ICU admission diagnoses, routinely measured laboratory values and vital signs, and relevant features manually extracted from echocardiogram and left heart catheterization reports. We externally validated the risk model on the New York University (NYU) Langone Health cardiac ICU database that was also annotated with physician adjudicated outcomes. The external validation cohort consisted of 131 patients with 25 patients experiencing cardiogenic/mixed shock. CShock achieved an area under the receiver operator characteristic curve (AUROC) of 0.821 (95% CI 0.792-0.850). CShock was externally validated in the more contemporary NYU cohort and achieved an AUROC of 0.800 (95% CI 0.717-0.884), demonstrating its generalizability in other cardiac ICUs. Having an elevated heart rate is most predictive of cardiogenic shock development based on Shapley values. The other top ten predictors are having an admission diagnosis of myocardial infarction with ST-segment elevation, having an admission diagnosis of acute decompensated heart failure, Braden Scale, Glasgow Coma Scale, Blood urea nitrogen, Systolic blood pressure, Serum chloride, Serum sodium, and Arterial blood pH. The novel CShock score has the potential to provide automated detection and early warning for cardiogenic shock and improve the outcomes for the millions of patients who suffer from myocardial infarction and heart failure.

The association of the Sequential Organ Failure Assessment score at intensive care unit discharge with intensive care unit readmission in the cardiac intensive care unit.

Unplanned intensive care unit (ICU) readmissions contribute to increased morbidity, mortality, and healthcare costs. The severity of patient illness at ICU discharge may predict early ICU readmission. Thus, in this study, we investigated the association of cardiac ICU (CICU) discharge Sequential Organ Failure Assessment (SOFA) score with unplanned CICU readmission in patients admitted to the CICU. We retrospectively reviewed the hospital medical records of 4659 patients who were admitted to the CICU from 2012 to 18. Sequential Organ Failure Assessment scores at CICU admission and discharge were obtained. The predictive performance of organ failure scoring was evaluated by using area under the receiver operating characteristic (AUROC) curves. The primary outcome was unplanned CICU readmission. Of the 3949 patients successfully discharged from the CICU, 184 (4.7%) had an unplanned CICU readmission or they experienced a deteriorated condition but died without being readmitted to the CICU (readmission group). The readmission group had significantly higher rates of organ failure in all organ systems at both CICU admission and discharge than the non-readmission group. The AUROC of the discharge SOFA score for CICU readmission was 0.731, showing good predictive performance. The AUROC of the discharge SOFA score was significantly greater than that of either the initial SOFA score (P = 0.020) or the Acute Physiology and Chronic Health Evaluation II score (P < 0.001). In the multivariable regression analysis, SOFA score, overweight or obese status, history of heart failure, and acute heart failure as reasons for ICU admission were independent predictors of unplanned ICU readmission during the same hospital stay. The discharge SOFA score may identify patients at a higher risk of unplanned CICU readmission, enabling targeted interventions to reduce readmission rates and improve patient outcomes.

Patients Aged 90 Years and Above With Acute Coronary Syndrome in the Cardiac Intensive Care Unit: Management and Outcomes

Limited data exist regarding outcomes after coronary angiography (CAG) and percutaneous coronary intervention (PCI) in patients aged ≥90 years admitted to the cardiac intensive care unit (CICU) with acute coronary syndrome (ACS). We studied sequential CICU patients ≥90 years admitted with ACS from 2007 to 2018. Three therapeutic approaches were defined: (1) No CAG; (2) CAG without PCI (CAG/No PCI); and (3) CAG with PCI (CAG/PCI). In-hospital mortality was evaluated using multivariable logistic regression. All-cause 1-year mortality was evaluated using Kaplan-Meier and multivariable Cox proportional hazards analysis. The study included 239 patients with a median age of 92 (range 90 to 100) years (57% females; 45% ST-elevation myocardial infarction; 8% cardiac arrest; 16% shock). The No CAG group had higher Day 1 Sequential Organ Failure Assessment scores, more co-morbidities, worse kidney function, and fewer ST-elevation myocardial infarctions. In-hospital mortality was 20.8% overall and did not differ between the No CAG (n = 103; 21.4%), CAG/No PCI (n = 47; 21.3%), and CAG/PCI (n = 90; 20.0%) groups, before or after adjustment. Overall 1-year mortality was 52.5% and did not differ between groups before or after adjustment. Median survival was 6.9 months overall and 41.2% of hospital survivors died within 1 year of CICU admission. CICU patients aged ≥90 years with ACS have a substantial burden of illness with high in-hospital and 1-year mortality that was not lower in those who underwent CAG or PCI. These results suggest that careful patient selection for invasive coronary procedures is essential in this vulnerable population.

Stress Ulcer Prophylaxis Versus Placebo-A Blinded Pilot Randomized Controlled Trial to Evaluate the Safety of Two Strategies in Critically Ill Infants With Congenital Heart Disease.

The routine use of stress ulcer prophylaxis (SUP) in infants with congenital heart disease (CHD) in the cardiac ICU (CICU) is controversial. We aimed to conduct a pilot study to explore the feasibility of performing a subsequent larger trial to assess the safety and efficacy of withholding SUP in this population (NCT03667703). Single-center, prospective, double-blinded, parallel group (SUP vs. placebo), pilot randomized controlled pilot trial (RCT) in infants with CHD admitted to the CICU and anticipated to require respiratory support for greater than 24 hours. Patients were randomized 1:1 (stratified by age and admission type) to receive a histamine-2 receptor antagonist or placebo until respiratory support was discontinued, up to 14 days, or transfer from the CICU, if earlier. Feasibility was defined a priori by thresholds of screening rate, consent rate, timely drug allocation, and protocol adherence. The safety outcome was the rate of clinically significant upper gastrointestinal (UGI) bleeding. We screened 1,426 patients from February 2019 to March 2022; of 132 eligible patients, we gained informed consent in 70 (53%). Two patients did not require CICU admission after obtaining consent, and the remaining 68 patients were randomized to SUP (n = 34) or placebo (n = 34). Ten patients were withdrawn early, because of a change in eligibility (n = 3) or open-label SUP use (n = 7, 10%). Study procedures were completed in 58 patients (89% protocol adherence). All feasibility criteria were met. There were no clinically significant episodes of UGI bleeding during the pilot RCT. The percentage of patients with other nonserious adverse events did not differ between groups. Withholding of SUP in infants with CHD admitted to the CICU was feasible. A larger multicenter RCT designed to confirm the safety of this intervention and its impact on incidence of UGI bleeding, gastrointestinal microbiome, and other clinical outcomes is warranted.

Serial Assessment of Shock Severity in Cardiac Intensive Care Unit Patients.

One-time assessment of the Society for Cardiovascular Angiography and Interventions (SCAI) shock classification robustly predicts mortality in the cardiac intensive care unit (CICU). We sought to determine whether serial SCAI shock classification could improve risk stratification. Unique admissions to a single academic level 1 CICU from 2015 to 2018 were included in this retrospective cohort study. Electronic health record data were used to assign the SCAI shock stage during 4-hour blocks of the first 24 hours of CICU admission. Shock was defined as hypoperfusion (SCAI shock stage C, D, or E). In-hospital death was evaluated using logistic regression. Among 2918 unique CICU patients, 1537 (52.7%) met criteria for shock during ≥1 block, and 266 (9.1%) died in the hospital. The SCAI shock stage on admission was: A, 37.6%; B, 31.5%; C, 25.9%; D, 1.8%; and E, 3.3%. Patients who met SCAI criteria for shock on admission (first 4 hours) and those with worsening SCAI shock stage after admission were at higher risk for in-hospital death. Each higher admission (adjusted odds ratio, 1.36 [95% CI, 1.18-1.56]; area under the receiver operating characteristic curve, 0.70), maximum (adjusted odds ratio, 1.59 [95% CI, 1.37-1.85]; area under the receiver operating characteristic curve, 0.73) and mean (adjusted odds ratio, 2.42 [95% CI, 1.99-2.95]; area under the receiver operating characteristic curve, 0.78) SCAI shock stage was incrementally associated with a higher in-hospital mortality rate. Discrimination was highest for the mean SCAI shock stage (P<0.05). Each additional 4-hour block meeting SCAI criteria for shock predicted a higher mortality rate (adjusted odds ratio, 1.15 [95% CI, 1.07-1.24]). Dynamic assessment of shock using serial SCAI shock classification assignment can improve mortality risk stratification in CICU patients by quantifying the magnitude and duration of shock.

Mayo Cardiac Intensive Care Unit Admission Risk Score (M-CARS) validation test to assess mortality during treatment in Cardiovascular Care Unit (CVCU) patients at Haji Adam Malik Hospital

Abstract&#x0D; Background: Approximately 85% of all in-hospital deaths occur in Cardiovascular Care Unit (CVCU) where M-CARS will be an important starting point for development of CVCU-specific mortality risk prediction models.&#x0D; Aim: This research aims to assess M-CARS validation to assess mortality during treatment in CVCU patients at Haji Adam Malik (HAM) General Hospital.&#x0D; Methods: This research is a prospective research that examines M-CARS score validity as a predictor of intra-hospital mortality in patients treated at CVCU HAM General Hospital Medan from September 2021 - January 2022. If correlation test results show a significant relationship, cut-off value M-CARS score will be taken using ROC (Receiver Operating Characteristic) curve analysis, then analysis of M-CARS score diagnostic value will be carried out according to cut-off value obtained to predict mortality during hospitalization. Then Hosmer-Lemeshow test was carried out to assess suitability of logistic regression on risk prediction assessment within population that being assessed.&#x0D; Results: M-CARS had a very good discriminatory ability (AUC 0.93) to predict intrahospital mortality. The calibration value using Hosmer Lemeshow test (R2 = 0.982; p = 1.516; p&gt;0.05) shows that there is no significant difference between observed and expected mortality rate by two scoring systems therefore considered as accurate.&#x0D; Conclusion: M-CARS is valid to be used in assessing risk of mortality events during CVCU treatment at H. Adam Malik Hospital Medan.&#x0D; Keywords: Mortality, Cardiovascular Care Unit, Mayo Cardiac Intensive Care Unit Admission Risk Score, Braden Score.

Noninvasive Hemodynamic Characterization of Shock and Preshock Using Echocardiography in Cardiac Intensive Care Unit Patients.

Shock and preshock are defined on the basis of the presence of hypotension, hypoperfusion, or both. We sought to determine the hemodynamic underpinnings of shock and preshock noninvasively using transthoracic echocardiography (TTE). We included Mayo Clinic cardiac intensive care unit patients from 2007 to 2015 with TTE within 1 day of admission. Hypotension and hypoperfusion at the time of cardiac intensive care unit admission were used to define 4 groups. TTE findings were evaluated across these groups, and in-hospital mortality was evaluated according to TTE findings in each group. We included 5375 patients with a median age of 69.2 years (36.8% women). The median left ventricular ejection fraction was 50%. Groups based on hypotension and hypoperfusion were assigned as follows: no hypotension or hypoperfusion, 59.7%; isolated hypotension, 15.3%; isolated hypoperfusion, 16.4%; and both hypotension and hypoperfusion, 8.7%. Most TTE variables of interest varied across these groups, with worse biventricular function, lower forward flow, and higher filling pressures as the degree of hemodynamic compromise increased. In-hospital mortality occurred in 8.2%, and inpatient deaths had more TTE parameter abnormalities. In-hospital mortality increased with the degree of hemodynamic compromise, and a marked gradient in in-hospital mortality was observed when the clinical classification of shock and preshock was combined with TTE findings reflecting worse biventricular function, lower forward flow, or higher filling pressures. Substantial differences in cardiac function are observed between cardiac intensive care unit patients with preshock and shock using TTE, and the combination of the clinical and TTE hemodynamic assessment provides robust mortality risk stratification.

Vasoactive medication requirements in the first 24 hours of cardiogenic shock: association with mortality and mechanical circulatory support

Abstract Background Vasoactive medications and Mechanical Circulatory Support (MCS) are both central to the contemporary management of cardiogenic shock (CS). There are limited data on the interaction between vasoactive medication dosing and MCS in patients with CS. Purpose We investigated the association between in-hospital mortality and vasoactive medication dosing among patients with CS who did and did not receive MCS during hospitalization. Methods We included patients with CS admitted to our cardiac intensive care unit (CICU) between 2007 and 2015. The peak combined vasoactive medication dose during the first 24 hours of CICU admission was recorded and converted to norepinephrine equivalents (NEE)(references 1 &amp; 2). The primary outcome was in-hospital mortality. Multivariable logistic regression was used to adjust for relevant variables and calculate adjusted odds ratios (OR). Results Of 1078 patients with CS (median age 69.0 years [Interquartile Range 59.1-77.3], 36.8% female, 59% with acute myocardial infarction), 721 (66.9%) received vasoactive medications in the first 24 hours and 510 (47.3%) received MCS (87% intra-aortic balloon pump). Among those receiving vasoactive medications during the first 24 hours, the median NEE was 0.16 (Interquartile Range 0.06-0.40) mcg/kg/min. In hospital mortality was 34.4% overall, and was lower among those who received MCS (26.1% versus 41.9%, p&amp;lt;0.001; adjusted OR 0.71 95% CI 0.50-0.99) and higher among those who received vasoactive medications (38.1% versus 26.9%, p&amp;lt;0.001). A gradient of mortality was observed according to the use of vasoactive medications and MCS (Fig. 1). We found a strong incremental association between in-hospital mortality and NEE (adjusted OR 1.11 per 0.1 mcg/kg/min, 95% CI 1.06–1.16, P&amp;lt;0.001; Fig. 2). Mortality was lower across the spectrum of NEE for patients who received MCS (Fig. 2). There was no statistically significant difference in the slope of the relationship between in-hospital mortality and NEE in patients who did and did not receive MCS (p = 0.86). Conclusion Increasing vasoactive medication requirement during the first 24 hours of CICU admission is incrementally associated with in-hospital mortality in CS, representing a simplified marker of shock severity. Patients who received MCS were at lower risk of mortality across the spectrum of vasopressor requirements, emphasizing the potential synergy between these two complementary approaches to hemodynamic support.Figure 1Figure 2

Abstract 12925: MICU Overflow Patients in the Cardiac Intensive Care Unit: Insights From the Critical Care Cardiology Trials Network Registry

Background: The cardiac intensive care unit (CICU) is designed to manage critically ill patients (pts) with acute cardiovascular (CV) conditions, but may be the site of care for pts with non-CV critical illness when medical ICU (MICU) beds are unavailable. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multicenter registry of consecutive admissions to CICUs in North America coordinated by the TIMI Study Group. Pts with no acute or major cardiac issues were designated as MICU overflow and were compared to those admitted with acute CV illness. A generalized mixed-effect regression model was used to adjust for age, sex, Sequential Organ Failure Assessment (SOFA) score and cardiac arrest while accounting for variability among centers. Results: Among 18,006 CICU admissions, 778 (4.3%) were MICU overflow, with a range of 0% to 26% among centers. MICU overflow rates trended lower over time (Fig-A) . In comparison to admissions with acute CV illness, MICU overflow patients were younger (60.0 vs 67.0 y, p&lt;0.001) and more likely to be female (45.6 vs 36.7%, p&lt;0.001). Comorbidities differed markedly between the 2 groups (Fig-B) . Presentation with cardiac arrest was more common among admissions with acute CV illness (12.9% vs 4.5%, p&lt;0.001). MICU overflow admissions had higher SOFA scores than those with acute CV illness (5.0 vs 3.0, p&lt;0.001). Resource utilization is shown in Fig-C . ICU LOS was similar (2.0 vs 2.2d, p=0.4). MICU overflow status was associated with a trend in CICU mortality (adj-OR 1.19, 95% CI 0.93-1.53, p=0.16) and significantly higher hospital mortality (adj-OR 1.69, 95% CI 1.36-1.73, p&lt;0.001) (Fig-D) . Conclusions: MICU overflow pts constitute a meaningful number of admissions to CICUs. These pts have more multi-system disease, greater baseline organ dysfunction, and higher hospital mortality than pts with acute CV illness. These findings reinforce the need for multidisciplinary CICU teams with expertise in all facets of critical care.

Abstract 11821: Association of Hemoglobin With Mortality Outcomes in the Critical Care Cardiology Trials Network (CCCTN) Registry

Introduction: Anemia is common in critically ill patients and is a known risk indicator for poor outcomes. Little is known about the impact of anemia on short term outcomes in the setting of cardiac critical illness. We examined the association of varying degrees of anemia with in-hospital outcomes in cardiac intensive care unit (CICU) admissions. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multicenter network of tertiary CICUs in North America coordinated by the TIMI Study Group. During annual campaigns, each center contributes at least 2-mo of all consecutive medical CICU admissions. Admissions were stratified according to baseline hemoglobin (Hgb). The association of Hgb and in-hospital mortality, CICU length of stay and hospital length of stay was examined by logistic regression with multivariable adjustment. Results: Among 17,759 admissions, the median baseline Hgb was 12.0 g/dL (IQR 10.0, 13.8). Patients with lower Hgb tended to be older and female with lower body weight and a greater burden of comorbidities. After adjusting for sex and other relevant covariates, a lower baseline Hgb was associated with higher odds of in-hospital death (p-trend &lt;0.0001), and longer CICU and hospital length of stay (p-trend &lt;0.0001). Conclusions: Anemia is prevalent in half of patients admitted to the CICU. Lower Hgb level, even well above standard transfusion thresholds, is independently associated with higher in-hospital mortality and longer length of stay in cardiac critical illness.

Abstract 16265: Precipitants of Acute Hemodynamic Instability in Patients With Hypertrophic Cardiomyopathy Admitted to the Cardiac Intensive Care Unit

Background: Hypertrophic cardiomyopathy (HCM) is the most common genetic heart disease in the United States which can infrequently present with acute hemodynamic instability. Our study aimed to identify the precipitants of acute cardiovascular decompensation resulting in Cardiac Intensive Care Unit (CICU) admission in patients with HCM. Methods: All patients admitted to Cleveland Clinic Cardiac Intensive Care Unit (CICU) between Jan 1 st , 2010, to Dec 31 st , 2021, with a diagnosis of CS and co-existing HCM were identified through electronic medical charts. Only those with previously uncorrected HCM in the form of no prior myectomy/alcohol septal ablation and not on mavacamten were included in our study. Chart review was performed by physician investigators to identify the etiology precipitating hemodynamic instability in these patients. Results: Overall, 2754 patients were admitted to our CICU with CS during the study period, of which 21 patients (1%) had coexisting uncorrected HCM. The median age of patients with HCM admitted to our CICU was 61 years, 52% (n=11) were females, and 86% (n=18) were White Americans. The in-hospital mortality of patients with HCM-CS was around 24% (n=5). Retrospective chart review to identify the precipitating agent revealed atrial fibrillation with rapid ventricular response (Afib-RVR) to be the most common precipitant (33%, n=7), followed by severe MR in the setting of dynamic outflow obstruction (19%, n=4) and non-obstructive heart failure (19%, n=4). Conclusion: Identification of the precipitating mechanisms is critical to manage HCM patients presenting with hemodynamic instability. Rapid atrial fibrillation appears to be the most common precipitant leading to hemodynamic instability in this population.

Abstract 13964: Dynamic Assessment of Shock Severity in Cardiac Intensive Care Unit Patients

Introduction: A single assessment of the SCAI shock classification robustly predicts mortality, and a repeat assessment may improve prognostication. Hypothesis: We hypothesized that frequent serial assignment of the SCAI shock stage could further improve risk stratification. Methods: Unique AHA Level 1 cardiac intensive care unit (CICU) admissions at a single center from 2015 to 2018 were reviewed retrospectively. Time-stamped electronic health record data were used to assign the SCAI shock stage in each 4-hour block during the first 24 hours of CICU admission. Shock was defined as SCAI shock stage C, D, or E. In-hospital mortality was evaluated using logistic regression. Results: Among 2,918 CICU patients, 1,537 (52.7%) met criteria for shock during &gt;=1 block and 266 (9.1%) died in hospital. The SCAI shock stage on admission was: A, 37.6%; B, 31.5%; C, 25.9%; D, 1.8%; E, 3.3%. Patients with worsening SCAI shock stage after admission (first 4 hours) were at higher risk of mortality ( Figure A ), as were patients who met SCAI criteria for shock (particularly those with shock on admission, Figure B ). The pattern was consistent in patients with acute coronary syndromes, heart failure, or cardiac arrest (who had very high mortality). Each higher admission (aOR 1.36, 95% CI 1.18-1.56, AUC 0.70), maximum (aOR 1.59, 95% CI 1.37-1.85, AUC 0.73) and 24 hour mean (aOR 2.42, 95% CI 1.99-2.95, AUC 0.78) SCAI shock stage were incrementally associated with increasing in-hospital mortality. Discrimination was highest for the mean SCAI shock stage (p &lt;0.05). Each additional 4 hour block meeting SCAI criteria for shock was associated with higher mortality (aOR 1.15, 95% CI 1.07-1.24). Conclusions: Dynamic assessment of shock using serial SCAI shock classification assignment can improve mortality risk stratification in CICU patients. Cumulative time in shock was a strong mortality risk indicator, highlighting the area under the curve of shock severity as an important determinant of outcomes.

Abstract 16235: Older Patients Presenting With Cardiogenic Shock Have Worse Outcomes: Insights From a Quaternary Referral Center Registry

Background Cardiogenic shock (CS) is a life-threatening clinical syndrome of reduced cardiac output that leads to multi-organ failure. Despite improvements in the possible therapies available, it remains a significant cause of morbidity and mortality among patients admitted to the Cardiac Intensive Care Unit (CICU). It remains unclear how age of the admitted patient may affect outcomes. Aim We investigated survival of CS patients admitted to a single quaternary North American center stratified by age. Methods: All CS patients aged 18 years and older admitted between January 2014 and December 2021 were identified from a prospective CICU admissions registry. Patients with durable left ventricular assist device (LVAD) and heart transplant (HT) were excluded, as were CICU readmissions during the index hospitalization. Patient characteristics, co-morbidities and outcome data were collected. Survival between age groups (&lt;30, 30-40, 40-50, 50-60, 60-70 and &gt;70 years old) was compared using Kaplan-Meier methods. A Cox proportional hazards model evaluating survival differences by age as a continuous variable was created and quantified the association between age and mortality with other covariates: sex, etiology, admission creatinine, sodium, lactate, white blood count (WBC) and mean arterial pressure (MAP). All analyses were right-censored for LVAD or HT. Results: 1284 CS patients were identified, with mean age 60 years, 71% male, 21% due to acute MI. In-hospital survival stratified by age was significantly different (figure), p(Log Rank&lt;0.001). In the unadjusted model, increasing age led to an increased mortality, hazard ratio (HR) 1.029, p&lt;0.001. In the adjusted model for mortality, age remained significant, HR 1.023, 95% confidence interval 1.015-1.030, p&lt;0.001. Conclusion In a contemporary CICU registry, patients admitted with CS had higher mortality with advancing age. This should be a consideration in planning the use of potentially limited CICU resources.

Association of Shock Index with Echocardiographic Parameters in Cardiac Intensive Care Unit

BackgroundA high shock index (SI), the ratio of heart rate (HR) to systolic blood pressure (SBP), has been associated with unfavorable outcomes. We sought to determine the hemodynamic underpinnings of an elevated SI using 2-D and doppler Transthoracic Echocardiography (TTE) in unselected cardiac intensive care unit (CICU) patients. MethodsWe included Mayo Clinic CICU admissions from 2007 to 2018 who were in sinus rhythm at the time of TTE. The SI was calculated using HR and SBP at the time of TTE. Patients were grouped according to SI: <0.7, 4012 (64%); 0.7–0.99, 1764 (28%); and ≥ 1.0, 513 (8%). Pearson's correlation coefficient was used to assess associations between continuous variables. ResultsWe included 6289 unique CICU patients, 58% of whom had acute coronary syndrome. The median age was 67.9 years old and 37.8% were females. The mean SI was 0.67 BPM/mmHg. As the SI increased, markers of left ventricular (LV) systolic function and forward flow decreased, including left ventricular ejection fraction (LVEF), fractional shortening, left ventricular outflow tract (LVOT) velocity time integral (VTI), stroke volume, LV stroke work index, and cardiac power output. Biventricular filling pressures increased, and markers of right ventricular function worsened with rising SI. Most TTE measurements reflecting LV function and forward flow were inversely correlated with SI, including LV stroke work index (r = −0.59) and LVOT VTI (r = −0.41), as were both systemic vascular resistance index (r = −0.43) and LVEF (r = −0.23). ConclusionCICU patients with elevated SI have worse biventricular function and systemic hemodynamics, particularly decreased stroke volume and related calculated TTE parameters. The SI is an easily available marker that can be used to identify CICU patients with unfavorable hemodynamics who may require further assessment.

Elevation of Urinary Liver-Type Fatty Acid-Binding Protein Is a Harbinger of Poor Patient Prognosis after Allogeneic Stem Cell Transplantation

Several recent studies have demonstrated that urinary levels of liver-type fatty acid-binding protein (L-FABP) can be used to stratify the prognosis of cardiac disease, cardiac intensive care unit admission, cirrhosis, and coronavirus disease 2019. Our initial prospective study revealed that urinary L-FABP (uL-FABP) was associated with a high probability of acute kidney injury after stem cell transplantation (SCT); however, the relevance of elevated uL-FABP to the prognosis of patients undergoing SCT remains to be determined. We aimed to investigate whether uL-FABP levels can be used to stratify patient prognosis after SCT. To achieve this aim, we conducted a new long-term follow-up study using data from patients enrolled in our preceding prospective cohort study. Patients were classified into high and low uL-FABP groups based on levels measured at baseline (ie, before initiating the conditioning regimen), using an uL-FABP cutoff of 8.4 μg/gCr, which was determined based on data from healthy adults. uL-FABP levels were also measured on days 0, 7, and 14 after SCT. Cox proportional hazard regression was used to examine the effects of each factor on survival outcomes, and Fine-Gray regression was used in the presence of competing risks. Multivariate analysis incorporating confounders was then performed for factors with P < .1 in univariate analysis. In total, 20 of 84 patients (23.8%), 57 of 84 patients (67.9%), 34 of 49 patients (69.4%), and 34 of 46 patients (73.9%) were classified into the high uL-FABP group at baseline and on days 0, 7, and 14, respectively. The 5-year overall survival (OS) rate was 23.9% in the high uL-FABP group and 68.9% in the low uL-FABP group. The multivariate analysis identified a high uL-FABP level at baseline as a significant prognostic factor for poor OS (hazard ratio [HR], 3.54; P=.002). The 5-year cumulative incidence rate for nonrelapse mortality (NRM) was 50.0% in the high uL-FABP group and 19.9% in the low uL-FABP group. In the multivariate analysis, high uL-FABP at baseline was a significant prognostic factor for NRM (HR, 3.37; P=.01). uL-FABP levels did not significantly stratify the cumulative incidence of relapse (HR, 2.13; P=.11). uL-FABP levels on days 0, 7, and 14 were not significant predictors of survival. High uL-FABP level before initiation of conditioning significantly influences OS and NRM following SCT, whereas a high uL-FABP level at any point after the conditioning regimen does not. Our results show that measuring uL-FABP level at baseline may be a simple way to predict survival in patients undergoing SCT.

Systematic influenza screening in cardiac intensive care units during the influenza season: A prospective study in Spain

BackgroundLittle is known about the incidence of influenza among admissions to the cardiac intensive care unit (C-ICU), accuracy of clinical suspicion, and influenza vaccination uptake. We evaluated the incidence of influenza at C-ICU admission during the influenza season, potential underdiagnosis, and vaccination uptake. MethodsProspective study at five C-ICUs during the 2017-2020 influenza seasons. A nasopharyngeal swab was collected at admission from patients who consented (n = 788). Testing was with Xpert®XpressFlu/RSV. ResultsInfluenza was detected in 43 patients (5.5%) (40 FluA; 3 FluB) and clinically suspected in 27 (62.8%). Compared to patients without influenza, patients with influenza more frequently had heart failure (37.2% vs 22.8%, P = 0.031), previous contact with relatives with influenza-like illnesses (23.3% vs 12.5%, P = 0.042), antimicrobial use (67.4% vs 23.2%, P <0.01), and need for mechanical ventilation (25.6% vs 14.5%, P = 0.048). Patients received oseltamivir promptly. We found no differences in mortality (11.6% vs 5.2%, P = 0.076). Patients with influenza more frequently had myocarditis (9.3% vs 0.9%, P <0.01) and pericarditis (7.0% vs 0.8%, P = 0.01). Overall, 43.0% of patients (339/788) were vaccinated (51.9% of those with a clear indication [303/584]). ConclusionInfluenza seems to be a frequently underdiagnosed underlying condition in admissions to the C-ICU. Influenza should be screened for at C-ICU admission during influenza epidemics.