Contemporary Cardiac Intensive Care Unit Research Articles

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 (<30, 30-40, 40-50, 50-60, 60-70 and >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<0.001). In the unadjusted model, increasing age led to an increased mortality, hazard ratio (HR) 1.029, p<0.001. In the adjusted model for mortality, age remained significant, HR 1.023, 95% confidence interval 1.015-1.030, p<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.

Resource use among patients with transcatheter cardiac valve procedures admitted to contemporary cardiac intensive care units: insights from CCCTN.

Resource use among patients with transcatheter cardiac valve procedures admitted to contemporary cardiac intensive care units: insights from CCCTN.

Family Engagement in the Adult Cardiac Intensive Care Unit: A Survey of Family Engagement Practices in the Cardiac Critical Care Trials Network.

Cardiovascular and critical care professional societies recommend incorporating family engagement practices into routine clinical care. However, little is known about current family engagement practices in contemporary cardiac intensive care units (CICUs). We implemented a validated 12-item family engagement practice survey among site investigators participating in the Critical Care Cardiology Trials Network, a collaborative network of CICUs in North America. The survey includes 9 items assessing specific engagement practices, 1 item about other family-centered care practices, and 2 open-ended questions on strategies and barriers concerning family engagement practice. We developed an engagement practice score by assigning 1 point for each family engagement practice partially or fully adopted at each site (max score 9). We assessed for relationships between the engagement practice score and CICU demographics. All sites (N=39; 100%) completed the survey. The most common family engagement practices were open visitation (95%), information and support to families (85%), structured care conferences (n=82%), and family participation in rounds (77%). The median engagement practice score was 5 (interquartile range, 4). There were no differences in engagement practice scores by geographic region or CICU type. The most commonly used strategies to promote family engagement were family presence during rounds (41%), communication (28%), and family meetings (28%). The most common barriers to family engagement were COVID-related visitation policies (38%) and resource limitations (13%). Family engagement practices are routinely performed in many CICUs; however, considerable variability exists. There is a need for strategies to address the variability of family engagement practices in CICUs.

Patients with transcatheter valve procedures admitted to contemporary cardiac intensive care units: insights from the CCCTN registry

Abstract Funding Acknowledgements Type of funding sources: None. Background Transcatheter cardiac valve procedures, including transcatheter aortic valve replacement (TAVR) and transcatheter edge-to-edge repair (TEER), have increased in the recent years. Peri-procedural management strategies, including whether there is a need for routine admission to cardiac intensive care units (CICUs), are not well defined. Purpose We aimed to describe the epidemiology of patients with transcatheter cardiac valve procedures admitted to contemporary CICUs. Methods We identified patients who underwent transcatheter cardiac valve procedures (TAVR or TEER) from CICUs in North America from 2017 to 2021 using data from the CCCTN (Critical Care Cardiology Trials Network) Registry. We assessed patient characteristics and the reason for triage to a CICU among those admitted for TAVR or TEER. Among patients admitted for TAVR or TEER, we further compared resource utilization and outcomes between patients (1) with an admission or CICU indication of post-procedural monitoring alone versus (2) admissions following TAVR or TEER for other reasons. Results Of 17,852 CICU admissions, 641 (3.6%) had a TAVR/TEER leading to or during their CICU stay. Compared with patients without a TAVR/TEER during CICU stay, patients with the procedure were older (median [IQR]: 80 [74-85] vs. 66 (55-75) years) and a history of coronary artery disease (54% vs. 36%, P<0.01). Monitoring alone, without another CICU indication at the time of admission, was the most frequent admission indication in patients with TAVR/TEER (n= 474, 74%). Patients admitted with TAVR or TEER for monitoring alone had low rates of any shock (2%) and mechanical ventilation (3%) and low SOFA scores (2 [1-4]); Figure). In contrast, patients with TAVR/TEER admitted for other indications had higher rates of shock (26%) and mechanical ventilation (25%) and higher SOFA scores (4 [3-7]). There were 0 cases of mechanical circulatory support (MCS) use in patients admitted for monitoring only. CICU (0.2% vs. 4.2%) and in-hospital (1.5% vs. 9.0%) mortality was multifold lower in patients with TAVR or TEER admitted for monitoring alone compared to patients with TAVR or TEER with an admission indication beyond monitoring. Conclusions In contemporary North American CICUs, nearly 3 of 4 admissions of patients with TAVR or TEER are for procedural monitoring alone. Need for advanced CICU therapies and mortality rates were low among patients admitted to the CICU for monitoring alone following TAVR or TEER. Given expected growth of these procedures over time, these observations highlight potential opportunities to redirect triage of the majority of patients following TAVR or TEER to less costly hospital units.

Presentation and Outcomes of Patients With Preoperative Critical Illness Undergoing Cardiac Surgery

BackgroundLittle is known about the prevalence and post-surgical outcomes associated with cardiac intensive care unit (CICU) therapeutics among CICU patients referred for cardiac surgery. ObjectivesThe purpose of this study was to investigate the clinical characteristics and outcomes of CICU patients referred for cardiac surgery from the intensive care unit. MethodsWe analyzed characteristics and outcomes of CICU admissions referred from the CICU for cardiac surgery during 2017 to 2020 across 29 centers. The primary outcome was in-hospital mortality. ResultsAmong 10,321 CICU admissions, 887 (8.6%) underwent cardiac surgery, including 406 (46%) coronary artery bypass graftings, 201 (23%) transplants or ventricular assist devices, 171 (19%) valve surgeries, and 109 (12%) other procedures. Common indications for CICU admission included shock (33.5%) and respiratory insufficiency (24.9%). Preoperative CICU therapies included vasoactive therapy in 52.2%, mechanical circulatory support in 35.9%, renal replacement in 8.2%, mechanical ventilation in 35.7%, and 17.5% with high-flow nasal cannula or noninvasive positive pressure ventilation. In-hospital mortality was 11.7% among all CICU admissions and 9.1% among patients treated with cardiac surgery. After multivariable adjustment, pre-op mechanical circulatory support and renal replacement therapy were associated with mortality, while respiratory support and vasoactive therapy were not. ConclusionsNearly 1 in 12 contemporary CICU patients receive cardiac surgery. Despite high preoperative disease severity, CICU admissions undergoing cardiac surgery had a comparable mortality rate to CICU patients overall; highlighting the ability of clinicians to select higher acuity patients with a reasonable perioperative risk.

Abstract 11340: Characteristics of Patients Admitted to a Contemporary Cardiac Intensive Care Unit With Valvular Cardiogenic Shock

Background: Cardiogenic shock (CS) is a heterogeneous clinical entity associated with poor outcomes. Patients with CS primarily due to an acute valvular dysfunction (valvular cardiogenic shock; VCS) constitute a unique cohort who remain poorly defined. We sought to define the prevalence and underlying patient characteristics of patients with VCS. 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 were retrospectively identified through electronic medical records and confirmed via physician directed chart review. Patients with CS were subsequently categorized into those with VCS and non-VCS depending on the primary etiology responsible for CS. Characteristics of patients with VCS were analyzed to descriptively define this entity. Patients with mixed shock and those with incomplete variables were excluded. Results: Overall, 2754 patients were admitted to our CICU with CS of which 511 (18.6%) were determined to have VCS. The median age of patients with VCS was higher than those with non-VCS (70 yrs vs 64yrs, P<0.001). Patients with VCS were also more likely to be females (40.5% vs 31.8%, P<0.001), have higher prevalence of atrial fibrillation (56.9% vs 48.5%, p=0.001), chronic obstructive pulmonary disease (26.4% vs 20%, p=0.002), and prior history of valve replacement or repair (29.7% vs 7.9%, p<0.001) (Table 1). Patients with VCS were also significantly less likely to have prior MI (19.4% vs 46.6%, p<0.001). The aortic valve was most commonly implicated; with more native valve dysfunction as compared to prosthetic valve dysfunction (73% vs 27%, p<0.001). (Figure 1). Conclusion: One in 5 patients admitted with CS has VCS with native valves and the aortic position being the common culprit. The availability and impact of emergent percutaneous structural-interventions on clinical outcomes in this population warrants investigation.

Patients With Acute Coronary Syndromes Admitted to Contemporary Cardiac Intensive Care Units: Insights From the CCCTN Registry.

With the improvement in outcomes for acute coronary syndrome (ACS), the practice of routine admission to cardiac intensive care units (CICUs) is evolving. We aimed to describe the epidemiology of patients with ACS admitted to contemporary CICUs. Using the CCCTN (Critical Care Cardiology Trials Network) Registry for consecutive medical CICU admissions across 26 advanced CICUs in North America between 2017 and 2020, we identified patients with a primary diagnosis of ACS at CICU admission and compared patient characteristics, resource utilization, and outcomes to patients admitted with a non-ACS diagnosis and across sub-populations of patients with ACS, including by indication for CICU admission. Of 10 118 CICU admissions, 29.4% (n=2978) were for a primary diagnosis of ACS, with significant interhospital variability (range, 13.4%-56.6%). Compared with patients admitted with a diagnosis other than ACS, patients with ACS had fewer comorbidities, lower acute severity of illness with less utilization of advanced CICU therapies (41.3% versus 66.1%, P<0.0001), and lower CICU mortality (5.4% versus 9.9%, P<0.0001). Monitoring alone, without another CICU indication at the time of admission, was the most frequent admission indication in patients with ACS (53.8%); less common indications in patients with ACS included respiratory insufficiency, shock, or the need for vasoactive therapy. Of patients with ACS admitted for monitoring alone, 94.8% did not subsequently require advanced intensive care unit therapies and had a low CICU length of stay (1.5 days [0.9-2.4] versus 2.6 [1.4-5.1], P<0.0001) and CICU mortality (0.6% versus 11.0%, P<0.0001), compared with patients with ACS with an admission indication beyond monitoring. In a registry of tertiary care CICUs, ACS represent ≈1/3 of all admissions with significant variability across hospitals. More than half of the ACS admissions to the CICU were for routine monitoring alone, with a low rate of complications and mortality. This observation highlights an opportunity for prospective studies to refine triage strategies for lower risk patients with ACS.

Staffing models in the cardiac intensive care unit.

The modern cardiac intensive care unit (CICU) has evolved into a high-intensity unit that cares for critically ill patients. Despite this transformation, changes to the staffing model and organizational structure in these specialized units have only recently begun to meet these challenges. We describe the most recent evidence which will inform future CICU staffing models. In the United States, the majority of CICUs are open as opposed to closed units, yet recent data suggests that transition to a closed staffing model is associated with a decrease in mortality. These reductions in mortality in closed CICUs are most pronounced in the most critically ill populations, such as patients with mechanical circulatory support, cardiac arrest, and respiratory failure. In addition, one study has shown that transition to a cardiac intensivist staffed CICU was associated with a reduction in mortality. Finally, multidisciplinary and protocolized teams imbedded within the CICU, specifically 'shock teams,' have recently been developed and may reduce mortality in this particularly sick patient population. Although the preponderance of data suggests improved outcomes with a closed, intensivist staffed CICU model, future multicenter studies are needed to better define the ideal staffing models for the contemporary CICU.

Bedside intra-aortic balloon pump insertion in cardiac intensive care unit: A single-center experience.

BackgroundIn contemporary Cardiac Intensive Care Unit (CICU), bedside intra‐aortic balloon pump (IABP) insertion under echocardiographic guidance may be an attractive option for selected patients with cardiogenic shock (CS). Currently available data on this approach are limited.AimThis study aimed to assess the feasibility and safety of bedside IABP insertion, as compared to fluoroscopic‐guided insertion in the Catheterization Laboratory (CathLab), and to describe the clinical features of patients receiving bedside IABP insertion using a standardized technique in real‐world CICU practice.MethodsWe prospectively evaluated all patients admitted the CICU who received transfemoral IABP between June 2020 and October 2021. The overall study cohort was divided according to implant strategy in bedside and CathLab groups. The primary outcome was correct radiographic IABP positioning at the first bedside chest X‐ray obtained after insertion. Secondary outcomes included IABP‐related complications.ResultsAmong 115 patients, bedside IABP insertion was performed in 35 (30.4%) cases, mainly presenting with CS‐related to acute decompensated heart failure (ADHF) (68.6 vs 33.8%; p < 0.001), with lower LVEF, higher proportion of right ventricular involvement and higher need of inotropes/vasopressors, compared to those receiving CathLab insertion. Bedside IABP insertion resulted feasible and safe, with similar rates of correct IABP positioning (82.9 vs. 82.5%; p = 0.963) and IABP‐related major vascular complications (5.7 vs. 5.0%; p = 0.874), as compared to CathLab positioning.ConclusionThis study suggests the feasibility and safety of bedside IABP insertion, which could be of relevant interest in patients with ADHF‐related CS who may not need coronary angiography or other urgent CathLab procedures.

Outcomes and Predictors of Mortality Among Cardiac Intensive Care Unit Patients With Heart Failure

BackgroundLittle is known regarding the causes of critical illness and determinants of prognosis of patients with heart failure (HF) admitted to the modern cardiac intensive care unit (CICU). We sought to describe the epidemiology and outcomes of patients with HF admitted to the contemporary CICU. Methods and ResultsRetrospective cohort analysis of Mayo Clinic CICU patients admitted with HF from 2007 to 2018 who had left ventricular ejection fraction (LVEF) data. HF with reduced LVEF (HFrEF) was defined as a LVEF of less than 50%, and HF with preserved LVEF (HFpEF) as a LVEF of 50% or greater. In-hospital mortality was analyzed using multivariable logistic regression. Survival to 1 year was analyzed using a Kaplan–Meier analysis. We included 4012 patients, including 67.8% with HFrEF and 32.2% with HFpEF. Patients with HFrEF and HFpEF were comparable and had equivalent severity of illness. Critical care therapies were used in 59.4%, with a slight preponderance in patients with HFrEF. In-hospital mortality occurred in 12.5% of patients and was similar in HFrEF vs HFpEF. Shock and cardiac arrest were the strongest predictors of adjusted in-hospital mortality, followed by Braden skin score and serum chloride level; patients with HFrEF and HFpEF had similar adjusted mortality rates. The 1-year survival after hospital discharge was 74.5% and was slightly lower for patients with HFpEF. All-cause rehospitalization occurred in 36.6%, and 52.8% of hospital survivors died or were readmitted within 1 year. ConclusionsCICU patients with HF have a substantial burden of critical illness, high use of critical care therapies, and poor outcomes regardless of LVEF. This finding emphasizes the potential unmet care needs in this cohort. Lay summaryPatients with heart failure who require admission to the cardiac intensive care unit have high severity of illness and are at significant risk of death during and after hospitalization. These patients often require specialized critical care therapies to treat manifestations of critical illness. Patients who are admitted with cardiac arrest or shock, including those who require mechanical ventilation or vasopressors, are at particularly high risk of death. Patients’ left ventricular ejection fraction is not strongly associated with the risk of death when accounting for other major predictors including frailty and laboratory abnormalities.

End-of-life care in the cardiac intensive care unit: a contemporary view from the Critical Care Cardiology Trials Network (CCCTN) Registry.

Increases in life expectancy, comorbidities, and survival with complex cardiovascular conditions have changed the clinical profile of the patients in cardiac intensive care units (CICUs). In this environment, palliative care (PC) services are increasingly important. However, scarce information is available about the delivery of PC in CICUs. The Critical Care Cardiology Trials Network (CCCTN) Registry is a network of tertiary care CICUs in North America. Between 2017 and 2020, up to 26 centres contributed an annual 2-month snapshot of all consecutive medical CICU admissions. We captured code status at admission and the decision for comfort measures only (CMO) before all deaths in the CICU. Of 13422 patients, 10% died in the CICU and 2.6% were discharged to palliative hospice. Of patients who died in the CICU, 68% were CMO at death. In the CMO group, only 13% were do not resuscitate/do not intubate at admission. The median time from CICU admission to CMO decision was 3.4 days (25th-75th percentiles: 1.2-7.7) and ≥7 days in 27%. Time from CMO decision to death was <24 h in 88%, with a median of 3.8 h (25th-75th 1.0-10.3). Before a CMO decision, 78% received mechanical ventilation and 26% mechanical circulatory support. A PC provider team participated in the care of 41% of patients who died. In a contemporary CICU registry, comfort measures preceded death in two-thirds of cases, frequently without PC involvement. The high utilization of advanced intensive care unit therapies and lengthy times to a CMO decision highlight a potential opportunity for early engagement of PC teams in CICU.

The Intersection of Heart Failure and Critical Care: The Contemporary Cardiac Intensive Care Unit and the Opportunity for a Unique Training Pathway

The Intersection of Heart Failure and Critical Care: The Contemporary Cardiac Intensive Care Unit and the Opportunity for a Unique Training Pathway

De Novo vs Acute-on-Chronic Presentations of Heart Failure-Related Cardiogenic Shock: Insights from the Critical Care Cardiology Trials Network Registry

Heart failure-related cardiogenic shock (HF-CS) accounts for an increasing proportion of cases of CS in contemporary cardiac intensive care units. Whether the chronicity of HF identifies distinct clinical profiles of HF-CS is unknown. We evaluated admissions to cardiac intensive care units for HF-CS in 28 centers using data from the Critical Care Cardiology Trials Network registry (2017-2020). HF-CS was defined as CS due to ventricular failure in the absence of acute myocardial infarction and was classified as de novo vs acute-on-chronic based on the absence or presence of a prior diagnosis of HF, respectively. Clinical features, resource use, and outcomes were compared among groups. Of 1405 admissions with HF-CS, 370 had de novo HF-CS (26.3%), and 1035 had acute-on-chronic HF-CS (73.7%). Patients with de novo HF-CS had a lower prevalence of hypertension, diabetes, coronary artery disease, atrial fibrillation, and chronic kidney disease (all P < 0.01). Median Sequential Organ Failure Assessment (SOFA) scores were higher in those with de novo HF-CS (8; 25th-75th: 5-11) vs acute-on-chronic HF-CS (6; 25th-75th: 4-9, P < 0.01), as was the proportion of Society of Cardiovascular Angiography and Intervention (SCAI) shock stage E (46.1% vs 26.1%, P < 0.01). After adjustment for clinical covariates and preceding cardiac arrest, the risk of in-hospital mortality was higher in patients with de novo HF-CS than in those with acute-on-chronic HF-CS (adjusted hazard ratio 1.36, 95% confidence interval 1.05-1.75, P = 0.02). Despite having fewer comorbidities, patients with de novo HF-CS had more severe shock presentations and worse in-hospital outcomes. Whether HF disease chronicity is associated with time-dependent compensatory adaptations, unique pathobiological features and responses to treatment in patients presenting with HF-CS warrants further investigation.

Past, present, and future of mortality risk scores in the contemporary cardiac intensive care unit.

Risk stratification dates to the dawn of the cardiac intensive care unit (CICU). As the CICU has evolved from a dedicated unit caring for patients with acute myocardial infarction to a complex healthcare environment encompassing a broad array of acute and chronic cardiovascular pathology, an expanding array of risk scores are available that can be applied to CICU patients. Most of these scores were designed for use either in patients with a specific acute cardiovascular diagnosis or unselected critically ill patients, and risk scores developed in other populations often underperform in the CICU. More recently, risk scores have been developed specific to the CICU population, demonstrating improved performance. All existing risk scores have relevant limitations, both in terms of performance and applicability to patient care. Risk scores have been predominantly developed to predict short-term mortality, either by quantifying severity of illness or by incorporating other risk factors for mortality. It is essential to distinguish mortality risk attributable to severity of illness, which may be modifiable through intervention, from mortality risk attributable to non-modifiable risk factors. This review discusses established risk scores applicable to the CICU population, details how risk score performance is characterized, describes how new risk scores can be developed, explains how the information provided by risk scores can be used in clinical practice, and highlights how novel risk stratification approaches can be developed.

Assessment of geriatrics outcomes in the cardiac intensive care unit

Objective: Critically ill older adults greater than or equal to 80 years old are routinely admitted to contemporary cardiac intensive care units (CICU). Little has been reported about their outcomes when compared to the general CICU population. The primary aim of this study was to compare the mortality, length-of-stay, and disposition outcomes of elderly patients (greater or equal to 80 years old) admitted to the CICU with a younger cohort (less than 80 years old).&#x0D; Methods and Results: A single-center, retrospective cohort study was conducted including 6,194 adult patients admitted to a cardiovascular intensive care unit in Newark, Delaware, from July 1, 2012, to June 30, 2019. Coronary intensive care unit (CICU) mortality, CICU length-of-stay and discharge disposition were compared between elderly patients (greater than or equal to 80 years old) and younger patients (less than 80 years old), adjusted for comorbidities.&#x0D; We observed increased mortality for elderly patients (OR 1.686, CI 1.361-2.090, p&lt;0.001) compared with patients less than 80 years old, even after adjusting for comorbidities. Median length of stay was not statistically different between the two groups. However, the elderly patients were significantly more likely to be discharged to a facility, such as a skilled nursing facility, than those less than 80 years old (26.8% versus 12.5%, respectively, p&lt;0.001).&#x0D; Conclusions: Among patients admitted to the CICU, elderly patients have higher mortality rates than those less than 80 years old. Advanced age (greater or equal to 80 years old) was not a reliable predictor of outcome in the CICU. A large proportion of elderly patients are not able to live independently at home after CICU admissions.&#x0D; Key Words: octogenarians, nonagenarians, cardiac intensive care unit, elderly, ICU mortality

Abstract 15759: Utility of the Sofa Score to Risk Stratify Patients in the Cardiac Intensive Care Unit at a Tertiary Care Center

Introduction: The Sequential Organ Failure Assessment (SOFA) score predicts intensive care unit (ICU) mortality within a medical ICU population but utility of the SOFA score in the contemporary cardiac ICU (CICU) is unclear. Methods: Data from consecutive patients with primary cardiac (PC) and non-cardiac (PNC) disease admitted to the CICU at a tertiary care center from 1/1/19-2/28/19 and 10/1/19-11/30/19 were collected and analyzed by retrospective chart review, including demographics, comorbidities, primary reasons for admission, labs and SOFA score parameters. Patients were grouped into three categories based on their highest SOFA score within the first 24 hours of CICU admission: SOFA Score ≤ 6, 7-11 and ≥ 12. CICU and in-hospital mortality rates (adjusted for age, gender, race, and comorbidities) were compared using multivariate linear regression. Results: Of the 453 patients admitted to the CICU during the studied time period, 321 had PC diagnoses and 132 PNC diagnoses. The mean age was 63.5 and 59.6 ( p&lt; 0.05) , 65.1% and 50.7% were male ( p&lt; 0.05) , and 53.6% and 62.9% were white ( p=0.07) , and 70.4% and 56.8% had at least three or more comorbidities ( p&lt;0.05) for the PC and PNC cohorts, respectively. The top three comorbidities were hypertension (70%), heart failure (39%), and diabetes mellitus (36%) for the PC group and hypertension (60%), diabetes mellitus (33%), and pulmonary disease (26%) for the PNC group, respectively. Increasing SOFA scores were associated with increased CICU and in-hospital mortality (Table) for patients with both PC and PNC diagnoses. Conclusion: Increased SOFA scores were associated with higher risk of CICU and in-hospital mortality. The SOFA score may be useful for risk stratification of CICU patients with both primary cardiac and non-cardiac diagnoses.

Abstract 15559: In-hospital versus Out-of-hospital Cardiac Arrest in Patients Presenting to Cardiac Intensive Care Units: From the Critical Care Cardiology Trials Network (CCCTN) Registry

Background: Cardiac arrest (CA) is a common reason for cardiac intensive care unit (CICU) admission and is associated with considerable morbidity, mortality, and resource use. Aim: To describe characteristics and outcomes of pts presenting to contemporary CICUs with in-hospital (IH) or out-of-hospital (OH) CA. Methods: The Critical Care Cardiology Trials Network (CCCTN) is a multicenter network of tertiary CICUs in North America (n=25). Participating centers contributed data from consecutive admissions during 2-month annual snapshots between 9/2017 and 8/2019 (n=8240). We analyzed characteristics and outcomes of pts with CA by IHCA vs OHCA. Results: Of 975 admissions with CA (48.9% OHCA), most were male (64.7%), Caucasian (63.4%) and smokers (60.6%). Acute coronary syndrome (ACS) was present in 30.6% and cardiomyopathy in 21.8%. Shockable rhythm was present in 54.1%, more commonly among those with reduced ejection fraction, ischemic cardiomyopathy, or ACS (p&lt;0.01 for all). Compared with IHCA, patients with OHCA were younger (median age 62 vs 66 years) and had fewer comorbidities including heart failure, atrial fibrillation, valvular disease, pulmonary HTN, and CKD (p&lt;0.01 for all). Pts with OHCA more commonly had shockable rhythms (58.3% vs 50.0%) and were more likely to be comatose at initial assessment (75.7% vs 40.4%); p&lt;0.01 for both. Resource use varied significantly between OHCA and IHCA [ Fig ] and CICU length of stay was longer for pts with OHCA (median 3.4 vs 3.1 days; p=0.049). In-hospital mortality was 41.2% and was higher in OHCA (44.7%) compared with IHCA (38.0%), p=0.03 [ Fig ]. Eventual discharge home or to rehab was more common among pts with IHCA (51.6% vs 49.1% for OHCA; p&lt;0.01). Conclusion: Despite advances in pre- and in-hospital care, pts presenting to contemporary CICUs with CA have high in-hospital mortality, with IHCA mortality only modestly lower than in OHCA. A better understanding of patterns may guide new approaches to improve patient outcomes.

Prevention of Complications in the Cardiac Intensive Care Unit: A Scientific Statement From the American Heart Association.

Contemporary cardiac intensive care units (CICUs) have an increasing prevalence of noncardiovascular comorbidities and multisystem organ dysfunction. However, little guidance exists to support the development of best-practice principles specific to the CICU. This scientific statement evaluates strategies to avoid the potentially preventable complications encountered within contemporary CICUs, focusing on those that are most applicable to the CICU environment. This scientific statement reviews evidence-based practices derived in non-CICU populations, assesses their relevance to CICU practice, and highlights key knowledge gaps warranting further investigation to attenuate patient risk.

Prevalence of Noncardiac Multimorbidity in Patients Admitted to Two Cardiac Intensive Care Units and Their Association with Mortality

BackgroundCurrent cardiac intensive care unit (CICU) practice has seen an increase in patient complexity, including an increase in noncardiac organ failure, critical care therapies, and comorbidities. We sought to describe the changing epidemiology of noncardiac multimorbidity in the CICU population. MethodsWe analyzed consecutive unique patient admissions to 2 geographically distant tertiary care CICUs (n = 16,390). We assessed for the prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities (diabetes, chronic lung, liver, and kidney disease, cancer, and stroke/transient ischemic attack) and their associations with hospital and postdischarge 1-year mortality using multivariable logistic regression. ResultsThe prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities was 37.7%, 31.4%, 19.9%, and 11.0%, respectively. Increasing noncardiac comorbidities were associated with a stepwise increase in mortality, length of stay, noncardiac indications for ICU admission, and increased utilization of critical care therapies. After multivariable adjustment, compared with those without noncardiac comorbidities, there was an increased hospital mortality for patients with 1 (odds ratio [OR] 1.30; 95% confidence interval [CI], 1.10-1.54, P = .002), 2 (OR 1.47; 95% CI, 1.22-1.77, P < .001), and ≥3 (OR 1.79; 95% CI, 1.44-2.22, P < .001) noncardiac comorbidities. Similar trends for each additional noncardiac comorbidity were seen for postdischarge 1-year mortality (P < .001, all). ConclusionsIn 2 large contemporary CICU populations, we found that noncardiac multimorbidity was highly prevalent and a strong predictor of short- and long-term adverse clinical outcomes. Further study is needed to define the best care pathways for CICU patients with acute cardiac illness complicated by noncardiac multimorbidity.

CAN THE SEQUENTIAL ORGAN FAILURE ASSESSMENT (SOFA) SCORE BE USED FOR RISK STRATIFICATION IN A TERTIARY CARDIAC INTENSIVE CARE UNIT POPULATION?

The Sequential Organ Failure Assessment (SOFA) score has been shown to predict intensive care unit (ICU) mortality within a general ICU population. Limited data exist regarding utility of the SOFA score in the contemporary cardiac ICU. Data from consecutive admissions for patients admitted to the