Cardiac Intensive Care Unit Patients Research Articles

C52 THE BIG FOUR: RESPIRATORY FAILURE, RENAL INSUFFICIENCY, HAEMORRHAGE AND SEPSIS, HOW DO THEY IMPACT ON CICU PATIENT?

Abstract Background The current rise in life expectancy in the general population leads to changes in baseline characteristics of Cardiac Intensive Care Unit (CICU) patients, increasing the risk of non–cardiac complications during the hospitalization. Objectives Evaluate epidemiology and prognostic impact of major non–cardiac complications (respiratory failure, renal insufficiency, haemorrhage and sepsis) during CICU stay. Methods: Retrospective analysis of CICU patients at Ospedale Maggiore of Bologna between March and November 2021. Results Baseline characteristics, cardiovascular risk factors and comorbidities of the patients are reported in Table 1. During the CICU stay, 19.7% of patients suffered from acute respiratory failure, needing for ventilation; 15.0% had renal insufficiency (considered as need for haemodialysis, glomerular filtration rate according to Cockcroft–Gault < 60 ml/min, serum creatinine rise > 25% from baseline); 1.8% reported major haemorrhages (defined as serum haemoglobin < 8 g/dl or need for blood transfusion); 1.7% developed sepsis (positive blood cultures). Mean CICU stay for complicated patients was 6 days, intra–CICU mortality was 1.7% (8 deaths) and 30–days mortality was 7.0% (32 deaths). At univariate logistic regression analysis, acute respiratory failure was the only complication associated with a statistically relevant increase in 30–days mortality (OR 2.37, CI 95%, 1.05–5.34; p = 0.038), although, also the other complications had a negative prognostic effect: haemorrhage (OR 1.58, CI 95%, 1.77–14.16; p = 0.681), renal insufficiency (OR 1.47, CI 95%, 0.56–3.87; p = 0.432) and sepsis (OR 1.25, CI 95%, 0.33–5.87, p = 0.850). Conclusions Epidemiology and baseline characteristics of CICU patients are changing. Older age and frailty make non–cardiac complications more likely to happen. Acute respiratory failure has the worst prognostic effect on mortality. This fact suggests that CICU Cardiologists should improve their management of these major non–cardiac complications.

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.

Peripheral blood neutrophil-to-lymphocyte ratio is associated with mortality across the spectrum of cardiogenic shock severity.

To evaluate the association between the neutrophil-to-lymphocyte ratio (NLR) and mortality across the cardiogenic shock (CS) severity spectrum, defined using the Society of Cardiovascular Interventions and Angiography (SCAI) shock stages. We retrospectively analyzed cardiac intensive care unit (CICU) patients between 2007 and 2015. Predictors of in-hospital mortality were analyzed using logistic regression. We included 8280 patients aged 67.3±15.2years (37.2% females). Elevated NLR (≥7) was present in 45% of patients. NLR increased with worsening SCAI stage and was associated with higher in-hospital mortality in shock stages A to C (all p<0.001). After multivariable adjustment, NLR remained associated with higher in-hospital mortality (adjusted odds ratio 1.05 per 3.5 NLR units, 95% CI 1.03-1.08, p<0.001), with an optimal cut-off of ≥7 (in-hospital mortality 13.1% vs. 4.1%, adjusted odds ratio 1.44, 95% CI 1.14-1.81, p=0.002). Patients in SCAI stage A or B with NLR ≥7 had higher in-hospital mortality than patients in SCAI stage B or C with NLR <7, respectively. Elevated NLR is associated with higher in-hospital mortality in CICU patients with or at risk for CS, emphasizing the importance of systemic inflammation as a determinant of outcomes in CS patients.

Automatic Critical Care Consultation Does Not Improve Outcomes For Patients Receiving Mechanical Ventilation In A Cardiac Intensive Care Unit Staffed By A Dedicated Heart Failure Specialist

Background The modern cardiac intensive care unit (CICU) cares for increasingly complex patients with multiorgan system dysfunction, often including respiratory failure. Preliminary data suggests that having an automatic critical care consultation for patients on mechanical ventilation may improve outcomes. Whether this dedicated consultation also improves outcomes in a closed CICU staffed by heart failure physicians is unknown. Methods We performed a single-center retrospective study of consecutive patients who were admitted to the CICU between 2010-2017 and required mechanical ventilation for more than 24 hours. In 2014, the CICU became closed and staffed primarily by a heart failure physician. At that time, a policy of automatic critical care consultation for all mechanically ventilated patients was also implemented. We collected data on demographics and hospital-course for patients admitted before and after these changes in order to compare mortality and ventilation/intubation outcomes. We controlled for baseline comorbidities using multiple linear and logistic regression analyses. Results There were 581 patients included in the study; 159 admitted before 2014 and 422 after 2014. The most common reason for intubation in both groups was hypoxic respiratory failure (57.3% vs 48.8%, p=0.20) followed by need for airway protection (26.4% vs. 37.5%, p=0.08). Those admitted after 2014 had a significant reduction in 30-day mortality (OR 0.49, p=0.007), 1-year mortality (OR 0.502, p=0.02) and a reduction in re-intubations (OR 0.395, p=0.0008). They were also much more likely to have received critical care consultation (76.2% vs 31.4% before 2014, P<0.00001). Overall, patients who received consultations were more likely to remain on mechanical ventilation longer in the CICU (1.8 more days, p=0.003) and to require more re-intubations (OR 4.06, p=0.0005). Even among patients admitted after 2014, critical care consultation in the CICU had no added effect on mortality or ventilator outcomes and was again associated with an excess of 1.6 days of mechanical ventilation (p = 0.03). Conclusion Cardiac patients requiring mechanical ventilation had significantly improved mortality and airway outcomes when cared for by a dedicated heart failure specialist. Automatic critical care consultation added no additional improvement in mortality and was associated with longer durations of mechanical ventilation and more re-intubations. Further prospective studies in ventilated patients in CICUs will be needed to continue to improve care for this population. The modern cardiac intensive care unit (CICU) cares for increasingly complex patients with multiorgan system dysfunction, often including respiratory failure. Preliminary data suggests that having an automatic critical care consultation for patients on mechanical ventilation may improve outcomes. Whether this dedicated consultation also improves outcomes in a closed CICU staffed by heart failure physicians is unknown. We performed a single-center retrospective study of consecutive patients who were admitted to the CICU between 2010-2017 and required mechanical ventilation for more than 24 hours. In 2014, the CICU became closed and staffed primarily by a heart failure physician. At that time, a policy of automatic critical care consultation for all mechanically ventilated patients was also implemented. We collected data on demographics and hospital-course for patients admitted before and after these changes in order to compare mortality and ventilation/intubation outcomes. We controlled for baseline comorbidities using multiple linear and logistic regression analyses. There were 581 patients included in the study; 159 admitted before 2014 and 422 after 2014. The most common reason for intubation in both groups was hypoxic respiratory failure (57.3% vs 48.8%, p=0.20) followed by need for airway protection (26.4% vs. 37.5%, p=0.08). Those admitted after 2014 had a significant reduction in 30-day mortality (OR 0.49, p=0.007), 1-year mortality (OR 0.502, p=0.02) and a reduction in re-intubations (OR 0.395, p=0.0008). They were also much more likely to have received critical care consultation (76.2% vs 31.4% before 2014, P<0.00001). Overall, patients who received consultations were more likely to remain on mechanical ventilation longer in the CICU (1.8 more days, p=0.003) and to require more re-intubations (OR 4.06, p=0.0005). Even among patients admitted after 2014, critical care consultation in the CICU had no added effect on mortality or ventilator outcomes and was again associated with an excess of 1.6 days of mechanical ventilation (p = 0.03). Cardiac patients requiring mechanical ventilation had significantly improved mortality and airway outcomes when cared for by a dedicated heart failure specialist. Automatic critical care consultation added no additional improvement in mortality and was associated with longer durations of mechanical ventilation and more re-intubations. Further prospective studies in ventilated patients in CICUs will be needed to continue to improve care for this population.

Implementation of a Nurse-Driven Spontaneous Awakening Trial Protocol in a Cardiac Intensive Care Unit.

In patients receiving mechanical ventilation, spontaneous awakening trials reduce morbidity and mortality when paired with spontaneous breathing trials. However, spontaneous awakening trials are not performed every day they are indicated and little is known about spontaneous awakening trial protocol use in cardiac intensive care units. Spontaneous awakening trial completion rate at the study institution was low and no trial protocol was regularly used. A preintervention-postintervention retrospective cohort study was performed in adult patients with at least 24 hours of invasive mechanical ventilation in Michigan Medicine's cardiac intensive care unit. Patients with SARS-CoV-2 infection were excluded. Data included demographics, sedation, mechanical ventilation duration, and in-hospital mortality. A nurse-driven spontaneous awakening trial protocol modified for the cardiac intensive care unit was implemented in October 2020. Compared with the preintervention cohort (n = 29, May through July 2020), the postintervention cohort (n = 27, October 2020 through February 2021) had a higher ratio of number of trials performed to number of days eligible for trial (0.91 vs 0.52; P < .01). Median continuous sedative infusion duration was shorter after intervention (2.3 vs 3.6 days; P = .02). Median mechanical ventilation duration (3.8 vs 4.7 days; P = .18) and mortality (41% vs 41%; P = .95) were similar between groups. Spontaneous awakening trial protocol implementation led to a higher trial completion rate and a shorter duration of continuous sedative infusion. Larger studies are needed to assess the impact of protocolized spontaneous awakening trials on cardiac intensive care unit patient outcomes.

A Simple Algorithm Using Ventilator Parameters to Predict Successfully Rapid Weaning Program in Cardiac Intensive Care Unit Patients.

Background: Ventilator weaning is one of the most significant challenges in the intensive care unit (ICU). Approximately 30% of patients fail to wean, resulting in prolonged use of ventilators and increased mortality. There are numerous high-performance prediction models available today, but they require a large number of parameters to predict and are thus impractical in clinical practice. Objectives: This study aims to create an artificial intelligence (AI) model for predicting weaning time and to identify the most simplified key predictors that will allow the model to achieve adequate accuracy with as few parameters as possible. Methods: This is a retrospective study of to-be-weaned patients (n = 1439) hospitalized in the cardiac ICU of Cheng Hsin General Hospital’s Department of Cardiac Surgery from November 2018 to August 2020. The patients were divided into two groups based on whether they could be weaned within 24 h (i.e., “patients weaned within 24 h” (n = 1042) and “patients not weaned within 24 h” (n = 397)). Twenty-eight variables were collected including demographic characteristics, arterial blood gas readings, and ventilation set parameters. We created a prediction model using logistic regression and compared it to other machine learning techniques such as decision tree, random forest, support vector machine (SVM), extreme gradient boosting, and artificial neural network. Forward, backward, and stepwise selection methods were used to identify significant variables, and the receiver operating characteristic curve was used to assess the accuracy of each AI model. Results: The SVM [receiver operating characteristic curve (ROC-AUC) = 88%], logistic regression (ROC-AUC = 86%), and XGBoost (ROC-AUC = 85%) models outperformed the other five machine learning models in predicting weaning time. The accuracies in predicting patient weaning within 24 h using seven variables (i.e., expiratory minute ventilation, expiratory tidal volume, ventilation rate set, heart rate, peak pressure, pH, and age) were close to those using 28 variables. Conclusions: The model developed in this research successfully predicted the weaning success of ICU patients using a few and easily accessible parameters such as age. Therefore, it can be used in clinical practice to identify difficult-to-wean patients to improve their treatment.

Prognostic utility of neutrophil gelatinase associated lipocalin in cardiac ICU: A prospective study

Our study aims to evaluate the role of neutrophil gelatinase associated lipocalin (NGAL) as an early surrogate marker in predicting acute kidney injury (AKI) and mortality in cardiac ICU patients. The study was conducted at SRN Hospital, excluding those with known renal diseases. Out of 152 patients, 56 developed AKI (cases) and 96 were our controls. Higher NGAL was associated with increased mortality rates (P = 0.0201 and 0.0255 for serum and urinary NGAL respectively). Our study concluded that NGAL measurement at admission may be a boon in improving the outcome of cardiac ICU patients.

Acute vital signs changes are underrepresented by a conventional electronic health record when compared with automatically acquired data in a single-center tertiary pediatric cardiac intensive care unit.

We sought to evaluate the fidelity with which the patient's clinical state is represented by the electronic health record (EHR) flow sheet vital signs data compared to a commercially available automated data aggregation platform in a pediatric cardiac intensive care unit (CICU). This is a retrospective observational study of heart rate (HR), systolic blood pressure (SBP), respiratory rate (RR), and pulse oximetry (SpO2) data archived in a conventional EHR and an automated data platform for 857 pediatric patients admitted postoperatively to a tertiary pediatric CICU. Automated data captured for 72h after admission were analyzed for significant HR, SBP, RR, and SpO2 deviations from baseline (events). Missed events were identified when the EHR failed to reflect the events reflected in the automated platform. Analysis of 132054622 data entries, including 264966 (0.2%) EHR entries and 131789656 (99.8%) automated entries, identified 15839 HR events, 5851 SBP events, 9648 RR events, and 2768 SpO2 events lasting 3-60min; these events were missing in the EHR 48%, 58%, 50%, and 54% of the time, respectively. Subanalysis identified 329 physiologically implausible events (eg, likely operator or device error), of which 104 (32%) were nonetheless documented in the EHR. In this single-center retrospective study of CICU patients, EHR vital sign documentation was incomplete compared to an automated data aggregation platform. Significant events were underrepresented by the conventional EHR, regardless of event duration. Enrichment of the EHR with automated data aggregation capabilities may improve representation of patient condition.

Echocardiographic left ventricular stroke work index: An integrated noninvasive measure of shock severity.

Echocardiographic findings vary with shock severity, as defined by the Society for Cardiovascular Angiography and Intervention (SCAI) shock stage. Left ventricular stroke work index (LVSWI) measured by transthoracic echocardiography (TTE) can predict mortality in the cardiac intensive care unit (CICU). We sought to determine whether LVSWI could refine mortality risk stratification by the SCAI shock classification in the CICU. We included consecutive CICU patients from 2007 to 2015 with TTE data available to calculate the LVSWI, specifically the mean arterial pressure, stroke volume index and medial mitral E/e' ratio. In-hospital mortality as a function of LVSWI was evaluated across the SCAI shock stages using logistic regression, before and after multivariable adjustment. We included 3635 unique CICU patients, with a mean age of 68.1 ± 14.5 years (36.5% females); 61.1% of patients had an acute coronary syndrome. The LVSWI progressively decreased with increasing shock severity, as defined by increasing SCAI shock stage. A total of 203 (5.6%) patients died during hospitalization, with higher in-hospital mortality among patients with lower LVSWI (adjusted OR 0.66 per 10 J/m2 higher) or higher SCAI shock stage (adjusted OR 1.24 per each higher stage). A LVSWI <33 J/m2 was associated with higher adjusted in-hospital mortality, particularly among patients with shock (SCAI stages C, D and E). The LVSWI by TTE noninvasively characterizes the severity of shock, including both systolic and diastolic parameters, and can identify low-risk and high-risk patients at each level of clinical shock severity.

Profile trends of non-COVID patients admitted to the cardiac intensive care unit during the 2020 COVID pandemic

BackgroundDuring the COVID-19 outbreak, numerous reports indicated a higher mortality rate among cardiovascular patients. We investigated how this trend applied to patients admitted to the cardiac intensive care unit (CICU). MethodsWe retrospectively compared CICU patients admitted during the initial peak of the COVID outbreak between February and May 2020 (Covid Era, CE group) to a control group in pre-pandemic time in 2019. We interviewed patients to determine the symptom onset time and the time interval between symptomology and hospital arrival. ResultsThe data of 292 patients were used in the analysis (119 patients in the CE group and 173 in the control group). CE patients had a higher incidence of ischemic heart disease (IHD) (p<.03), heart failure (p<.04), and psychiatric disorders (p<.001). During COVID time, more patients were hospitalized with myocarditis (OR: 26.45), arrhythmias (OR: 2.88), and new heart failure (HF) (p<.001) and less with STEMI (OR: 0.39; 95% CI: 0.24–0.63). Fewer PCIs were performed in the CE group (p<.001), with an overall lower success rate (p<.05) than reported in the control group. Patients in the CE group reported a longer period between symptom onset to hospital arrival (p<.001, χ2 = 12.42). The six-month survival rate was significantly lower in CE patients (χ2 = 7.01, P = 0.008). ConclusionsAmong CICU patients admitted to our center during the initial period of the COVID pandemic, STEMI events were less frequent while cases of newly diagnosed HF sharply increased. Patients waited longer after symptom onset before seeking medical care during the pandemic. The delay may have resulted in clinical deterioration that could explain the high mortality rate and the new HF admission rate.

Quantification of Vasoactive Medications and the "Pharmaco-Mechanical Continuum" in Cardiogenic Shock.

Quantification of Vasoactive Medications and the "Pharmaco-Mechanical Continuum" in Cardiogenic Shock.

A Novel Situational Awareness Scoring System in Pediatric Cardiac Intensive Care Unit Patients

AbstractThe aim of this study was to describe a novel Situational Awareness Scoring System (SASS)'s performance in discriminating between patients who had cardiac arrest (CA) and those who did not, in a pediatric cardiac intensive care unit (PCICU). Retrospective, observational-cohort study in a quaternary-care PCICU. Patients who had CA in the PCICU between January 2014 and December 2018, and patients admitted to the PCICU in 2018 who did not have CA were included. Patients with do not resuscitate or do not intubate orders, extracorporeal membrane oxygenation, ventricular assist device, and PCICU stay &lt; 2 hours were excluded. SASS score statistics were calculated within 2, 4-, 6-, and 8-hour time intervals counting backward from the time of CA, or end of PCICU stay in patients who did not have CA. Cross-validated discrete time logistic regression models were used to calculate area under the receiver operating characteristic (AUC) curves. Odds ratios (ORs) for CA were calculated per unit increase of the SASS score. Twenty-eight CA events were analyzed in 462 PCICU admissions from 267 patients. Maximum SASS score within 4-hour time interval before CA achieved the highest AUC of 0.91 (95% confidence interval [CI]: 0.86–0.96) compared with maximum SASS score within 2-, 6-, and 8-hour time intervals before CA of 0.88 (0.79–96), 0.90 (0.85–0.95), and 0.89 (0.83–0.95), respectively. A cutoff value of 60 for maximum SASS score within 4-hour time interval before CA resulted in 82.1 and 83.2% of sensitivity and specificity, respectively. OR for CA was 1.32 (95% CI: 1.26–1.39) for every 10 units increase in the maximum SASS score within each 4-hour time interval before CA. The maximum SASS score within various time intervals before CA achieved promising performance in discriminating patients regarding occurrence of CA.

Validation of cardiogenic shock phenotypes in a mixed cardiac intensive care unit population.

Proposed phenotypes have recently been identified in cardiogenic shock (CS) populations using unsupervised machine learning clustering methods. We sought to validate these phenotypes in a mixed cardiac intensive care unit (CICU) population of patients with CS. We included Mayo Clinic CICU patients admitted from 2007 to 2018 with CS. Agnostic K means clustering was used to assign patients to threeclusters based on admission values of estimated glomerular filtration rate, bicarbonate, alanine aminotransferase, lactate, platelets, and white blood cell count. In-hospital mortality and 1-year mortality were analyzed using logistic regression and Cox proportional-hazards models, respectively. We included 1498 CS patients with a mean age of 67.8 ± 13.9 years, and 37.1% were females. The acute coronary syndrome was present in 57.3%, and cardiac arrest was present in 34.0%. Patients were assigned to clusters as follows: Cluster 1 (noncongested), 603 (40.2%); Cluster 2 (cardiorenal), 452 (30.2%); and Cluster 3 (hemometabolic), 443 (29.6%). Clinical, laboratory, and echocardiographic characteristics differed across clusters, with the greatest illness severity in Cluster 3. Cluster assignment was associated with in-hospital mortality across subgroups. In-hospital mortality was higher in Cluster 3 (adjusted odds ratio [OR]: 2.6 vs. Cluster 1 and adjusted OR: 2.0 vs. Cluster 2, both p < 0.001). Adjusted 1-year mortality was incrementally higher in Cluster 3 versus Cluster 2 versus Cluster 1 (all p < 0.01). We observed similar phenotypes in CICU patients with CS as previously reported, identifying a gradient in both in-hospital and 1-year mortality by cluster. Identifying these clinical phenotypes can improve mortality risk stratification for CS patients beyond standard measures.

Shock Severity Assessment in Cardiac Intensive Care Unit Patients With Sepsis and Mixed Septic-Cardiogenic Shock.

We sought to validate the Society for Cardiovascular Angiography and Interventions (SCAI) cardiogenic shock classification for mortality risk stratification in patients with sepsis and concomitant cardiovascular disease or mixed septic-cardiogenic shock. We conducted a single-center retropective cohort study of cardiac intensive care unit patients with an admission diagnosis of sepsis. We used clinical, vital sign, and laboratory data during the first 24 hours after admission to assign SCAI shock stage. We included 605 patients with a median age of 69.4 years (interquartile range, 57.9 to 79.8 years), 222 of whom (36.7%) were female. Acute coronary syndrome or heart failure was present in 480 patients (79.3%), and cardiogenic shock or cardiac arrest was present in 271 patients (44.8%). The median day 1 Sequential Organ Failure Assessment (SOFA) cardiovascular subscore was 1.5 (interquartile range, 1 to 4), and the admission SCAI shock stage distribution was stage B, 40.7% (246); stage C, 19.3% (117); stage D, 32.9% (199); and stage E, 7.1% (43). In-hospital mortality occurred in 177 of the 605 patients (29.3%) and increased incrementally with higher SCAI shock stage. After multivariable adjustment, admission SCAI shock stage was associated with in-hospital mortality (adjusted odds ratio per stage, 1.46; 95% CI, 1.14 to 1.88; P=.003). Admission SCAI shock stage had higher discrimination for in-hospital mortality than the day 1 SOFA cardiovascular subscore (area under the receiver operating characteristic curve, 0.68 vs 0.64; P=.04 by the DeLong test). Admission SCAI shock stage was associated with 1-year mortality (adjusted hazard ratio per stage, 1.19; 95% CI, 1.03 to 1.37; P=.02). The SCAI shock classification provides improved mortality risk stratification over the day 1 SOFA cardiovascular subscore in cardiac intensive care unit patients with sepsis and concomitant cardiovascular disease or mixed septic-cardiogenic shock.

Noninvasive echocardiographic cardiac power output predicts mortality in cardiac intensive care unit patients

Low cardiac power output (CPO), measured invasively, can identify critically ill patients at increased risk of adverse outcomes, including mortality. We sought to determine whether non-invasive, echocardiographic CPO measurement was associated with mortality in cardiac intensive care unit (CICU) patients. Patients admitted to CICU between 2007 and 2018 with echocardiography performed within one day (before or after) admission and who had available data necessary for calculation of CPO were evaluated. Multivariable logistic regression determined the relationship between CPO and adjusted hospital mortality. A total of 5,585 patients (age of 68.3 ± 14.8 years, 36.7% female) were evaluated with admission diagnoses including acute coronary syndrome (ACS) in 56.7%, heart failure (HF) in 50.1%, cardiac arrest (CA) in 12.2%, shock in 15.5%, and cardiogenic shock (CS) in 12.8%. The mean left ventricular ejection fraction (LVEF) was 47.3 ± 16.2%, and the mean CPO was 1.04 ± 0.37 W. There were 419 in-hospital deaths (7.5%). CPO was inversely associated with the risk of hospital mortality, an association that was consistent among patients with ACS, HF, and CS. On multivariable analysis, higher CPO was associated with reduced hospital mortality (OR 0.960 per 0.1 W, 95CI 0.0.926-0.996, P=.03). Hospital mortality was particularly high in patients with low CPO coupled with reduced LVEF, increased vasopressor requirements, or higher admission lactate. Echocardiographic CPO was inversely associated with hospital mortality in unselected CICU patients, particularly among patients with increased lactate and vasopressor requirements. Routine calculation and reporting of CPO should be considered for echocardiograms performed in CICU patients.

Platelet-lymphocyte ratio as a new predictor of in-hospital mortality in cardiac intensive care unit patients

It has been discovered that both inflammation and platelet aggregation could cause crucial effect on the occurrence and development of cardiovascular diseases. As a combination of platelet and lymphocyte, platelet-lymphocyte ratio (PLR) was proved to be correlated with the severity as well as prognosis of cardiovascular diseases. Exploring the relationship between PLR and in-hospital mortality in cardiac intensive care unit (CICU) patients was the purpose of this study. PLR was calculated by dividing platelet count by lymphocyte count. All patients were grouped by PLR quartiles and the primary outcome was in-hospital mortality. The independent effect of PLR was determined by binary logistic regression analysis. The curve in line with overall trend was drawn by local weighted regression (Lowess). Subgroup analysis was used to determine the relationship between PLR and in-hospital mortality in different subgroups. We included 5577 CICU patients. As PLR quartiles increased, in-hospital mortality increased significantly (Quartile 4 vs. Quartile 1: 13.9 vs. 8.3, P < 0.001). After adjusting for confounding variables, PLR was proved to be independently associated with increased risk of in-hospital mortality (Quartile 4 vs. Quartile 1: OR 95% CI 1.55, 1.08–2.21, P = 0.016, P for trend < 0.001). The Lowess curves showed a positive relationship between PLR and in-hospital mortality. The subgroup analysis revealed that patients with low Acute Physiology and Chronic Health Evaluation IV (APACHE IV) or with less comorbidities had higher risk of mortality for PLR. Further, PLR quartiles had positive relation with length of CICU stay (Quartile 4 vs. Quartile 1: 2.7, 1.6–5.2 vs. 2.1, 1.3–3.9, P < 0.001), and the length of hospital stay (Quartile 4 vs. Quartile 1: 7.9, 4.6–13.1 vs. 5.8, 3.3–9.8, P < 0.001). PLR was independently associated with in-hospital mortality in CICU patients.

Safe Triage of STEMI Patients to General Telemetry Units After Successful Primary Percutaneous Coronary Intervention.

ObjectiveTo analyze outcomes of patients with ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (PCI) triaged to the cardiac intensive care unit (CICU) vs a general telemetry unit by a Zwolle risk score–based algorithm.MethodsWe introduced a quality improvement protocol in 2014 encouraging admission of STEMI patients with Zwolle score of 3 or less to general telemetry units unless they were hemodynamically unstable. We subsequently conducted a retrospective single-center cohort study of consecutive STEMI patients who had undergone primary PCI from January 1, 2014, to December 31, 2018. Outcomes studied include immediate complications, need for urgent unplanned intervention, need for CICU care, length of hospitalization, and survival.ResultsWe identified 547 patients, 406 with a Zwolle score of 3 or less. Of these, 192 (47.3%) were admitted to general telemetry and 214 (52.7%) to the CICU. Reasons for CICU admission included persistent chest pain, late presentation, and procedural complications. The average hospital length of stay was 2.1±1.4 days for non-CICU patients and 3.3±2.8 days for low-risk CICU patients (P<.001). Two patients initially admitted to general telemetry required transfer to the CICU. There were 26 patients who required unplanned cardiovascular intervention within 30 days, 5 from the general telemetry unit; 540 patients survived to discharge. One in-hospital death occurred among those initially triaged to the general telemetry unit, and this was due to a noncardiac cause.ConclusionA Zwolle score–based algorithm can be used to safely triage post-PCI STEMI patients to a general telemetry unit.

Abstract 10332: Biventricular Function and Shock Severity Predicts Mortality in Cardiac Intensive Care Unit Patients

Introduction: Ventricular dysfunction contributes to shock in cardiac intensive care unit (CICU) patients. We aimed to describe the associations between ventricular dysfunction with in-hospital mortality across the spectrum of shock severity. Hypothesis: Patients with biventricular dysfunction (BVD) have higher mortality at each Society for Cardiovascular Angiography and Intervention (SCAI) shock stage. Methods: We identified CICU patients from 2007 to 2015 with available echocardiography data within 1 day of admission. Left ventricular systolic dysfunction (LVSD) was defined as left ventricular ejection fraction &lt;40% and right ventricular systolic dysfunction (RVSD) as moderate or greater systolic dysfunction by semi-quantitative assessment; BVD included the presence of both LVSD and RVSD. Predictors of in-hospital mortality were determined after adjustment using multivariable logistic regression. Results: We included 3,158 patients with a mean age of 68.2±14.6 years; 51.8% had acute coronary syndromes. LVSD was present in 22.3%, RVSD in 11.8%, and 16.4% had BVD. Hospital mortality increased with SCAI shock stage and was incrementally higher in patients with LVSD, RVSD and BVD across SCAI shock stages (Figure); patients with BVD had higher mortality in each SCAI shock stage. After adjustment, there was no difference in in-hospital mortality for patients with LVSD or RVSD versus those without ventricular dysfunction (p &gt;0.05), but BVD was independently associated with higher in-hospital mortality (adjusted HR 1.815, 95% CI 1.237-2.663, p = 0.0023). Adding ventricular dysfunction to SCAI shock stage increased discrimination for hospital mortality (AUC 0.784 vs. 0.766, p &lt;0.001). Conclusions: Among patients admitted to the CICU, BVD was independently associated with higher hospital mortality after adjustment for shock severity. Echocardiographic assessment may augment clinical risk stratification using the SCAI shock classification.

Abstract 10652: Epidemiology and Outcomes of Pulmonary Hypertension in the Cardiac Intensive Care Unit

Introduction: Pulmonary hypertension (PH), defined as an elevated mean pulmonary artery pressure, has been consistently associated with adverse outcomes in hospitalized patients. Limited epidemiologic data exist regarding PH in the cardiac intensive care unit (CICU) population. We used transthoracic echocardiography (TTE) to describe the prevalence, etiology, and outcomes of PH in the CICU. Hypothesis: PH will be associated with higher in-hospital mortality in CICU patients. Methods: CICU patients admitted from 2007 to 2018 who had right ventricular systolic pressure (RVSP) measured via TTE within 1 day of CICU admission were included. PH was defined as an estimated RVSP &gt;35 mmHg. Predictors of in-hospital mortality were determined using multivariable logistic regression. Results: We included 5042 patients with a mean age of 69.4±14.8 (41% females); 81.1% had an admission diagnosis of acute coronary syndrome or heart failure. PH was present in 3085 (61%); the majority (68%) of patients with PH had left heart failure, and 29% had lung disease. In-hospital mortality occurred in 8% and was higher in patients with PH (11% vs. 4%, adjusted OR 1.40, 95% CI 1.03-1.92, p =0.03). PH was associated with higher in-hospital mortality in patients with acute coronary syndrome, heart failure or cardiac arrest (all p &lt;0.01), but not in patients with cardiogenic shock, respiratory failure or sepsis ( Figure ). In-hospital mortality increased as a function of higher RVSP in each admission diagnosis group (adjusted 1.18 per 10 mmHg higher in the entire cohort, 95% CI 1.09-1.28, p &lt;0.001). Conclusions: PH by TTE is very common in the CICU population and remains associated with a higher risk of death during hospitalization even after adjustment. TTE assessment of right heart hemodynamics can predict mortality in CICU patients, with variability across common admission diagnoses. This highlights the importance of PH determined by TTE in hospitalized patients with cardiac critical illness.

Echocardiography in the intensive care unit: An essential tool for diagnosis, monitoring and guiding clinical decision-making.

In the last years, new trends on patient diagnosis for admission in cardiac intensive care unit (CICU) have been observed, shifting from acute myocardial infarction or acute heart failure to non-cardiac diseases such as sepsis, acute respiratory failure or acute kidney injury. Moreover, thanks to the advances in scientific knowledge and higher availability, there has been increasing use of positive pressure mechanical ventilation which has its implications on the heart. Therefore, there is a growing need for Cardiac intensivists to quickly, noninvasively and repeatedly evaluate various hemodynamic conditions and the response to therapy. Transthoracic critical care echocardiography (CCE) currently represents an essential tool in CICU, as it is used to evaluate biventricular function and complications following acute coronary syndromes, identify the mechanisms of circulatory failure, acute valvular pathologies, tailoring and titrating intravenous treatment or mechanical circulatory support. This could be completed with trans-esophageal echocardiography (TOE), advanced echocardiography and lung ultrasound to provide a thorough evaluation and monitoring of CICU patients. However, CCE could sometimes be challenging as the acquisition of good-quality images is limited by mechanical ventilation, suboptimal patient position or recent surgery with drains on the chest. Moreover, there are some technical caveats that one should bear in mind while performing CCE in order to optimize its use and avoid misleading findings. The aim of this review is to highlight the key role of CCE, providing an updated overview of its main applications and possible pitfalls in order to facilitate its use in CICU for clinical decision-making.