Faculty Bibliography

BACKGROUND:Emerging therapies for acute PE highlight the need for a more granular risk classification. AIMS/OBJECTIVE:The objective of this study was to validate a novel risk model-the RIsk claSsification Adapted to SCAI shock stages in acute PE (RISA-PE), which applies the SCAI shock staging framework to right ventricular failure due to acute PE. METHODS:We retrospectively analyzed consecutive patients with acute intermediate- or high-risk PE treated with LBMT at a tertiary academic center (October 2020 to May 2025). Patients were stratified by RISA-PE stage (A-E) as previously described. Clinical data, including invasive pulmonary artery catheter hemodynamics and clinical outcomes were compared across stages. The primary endpoint was a composite of 30-day PE-related death, resuscitated cardiac arrest, or hemodynamic instability. RESULTS:) rising from 25% in Stage A to 75% in Stage C (p < 0.001). Clinical outcomes paralleled stage severity. Median hospital length-of-stay increased from 5 to 6 days (Stages A/B) to 19.9 days (Stage E, p < 0.001), and ICU stay from 2.5 to 3 days to 9.5 days, respectively (p < 0.001). The primary composite outcome occurred in 0% of Stage A, 5% of Stage B, 12% of Stage C, 15% of Stage D, and 50% of Stage E patients (p < 0.001). CONCLUSIONS:The RISA-PE staging system demonstrates strong correlation with RV dysfunction severity, invasive hemodynamics, and adverse outcomes in patients with acute PE treated with LBMT. RISA-PE provides a graded framework for identifying patients at highest risk of deterioration and may guide escalation of therapy.

Medications used to provide comfort in the cardiovascular intensive care unit exert complex cardiovascular and respiratory effects, necessitating careful selection based on risk-benefit assessments. Hemodynamic effects include changes in vascular tone which can alter preload and afterload, along with chronotropic and inotropic effects which may cause tachyarrhythmias or bradyarrhythmias, affect contractility and lusitropy, and compromise cardiac output and myocardial oxygen consumption. Drug-induced respiratory depression can also be limiting. This review synthesizes evidence on the cardiovascular and respiratory impact of anesthetics, sedatives, and analgesics and proposes a clinical decision framework tailored to pathophysiology. It is essential to recognize that the selection of drugs based on their properties and the patient's profile and hemodynamic/respiratory reserve provides only an empiric first step. Given varied physiology and disease heterogeneity and high comorbidity burden of cardiovascular intensive care unit patients, it is paramount to start with individualized conservatively dose-adjusted strategies followed by frequent assessment and tailoring of regimens as appropriate.

AIMS/OBJECTIVE:Optimal positive end-expiratory pressure (PEEP) selection in cardiogenic shock (CS) remains poorly defined despite the frequent use of invasive mechanical ventilation in this population. We aimed to evaluate whether a respiratory mechanics-guided PEEP titration protocol results in clinically relevant changes in ventilator settings and to assess the hemodynamic consequences of these adjustments. METHODS AND RESULTS/RESULTS:A prospective physiological study was conducted in mechanically ventilated patients with CS undergoing a decremental PEEP titration protocol (15 to 5 cmH2O). The final PEEP was selected according to maximal respiratory system compliance without evidence of derecruitment, overdistension, or hemodynamic deterioration. Hemodynamic, echocardiographic, and respiratory parameters were assessed at each step. Twenty-five patients were included, including 15 with acute myocardial infarction-related CS (AMI-CS) and 10 with heart failure-related CS (HF-CS). PEEP titration resulted in modification of ventilatory settings in 88% of patients. PEEP reduction occurred predominantly in AMI-CS, whereas PEEP escalation was more common in HF-CS. Respiratory mechanics and oxygenation improved following titration, with higher static compliance (62.5 ± 11 vs. 74.7 ± 11.5 mL/cmH2O; p = 0.003) and PaO2/FiO2 ratio (244 ± 89 vs. 276 ± 65; p = 0.001). Right atrial pressure (RAP) varied significantly across PEEP levels (p < 0.001) and changes were greater in HF-CS and in patients with RV dysfunction. Patients with impaired RV function showed greater RAP increase and reduced tolerance to higher PEEP levels. CONCLUSION/CONCLUSIONS:Respiratory mechanics-guided PEEP titration frequently modifies ventilatory settings in CS and reveals marked variability in hemodynamic tolerance according to CS phenotype and RV function. Individualized PEEP titration may help balance respiratory benefit, congestion, and hemodynamic stability in mechanically ventilated patients with cardiogenic shock.

BACKGROUND:Respiratory failure frequently complicates cardiogenic shock (CS), yet the optimal initial ventilatory strategy remains uncertain. Whether a noninvasive ventilation (NIV)-first approach is associated with worse outcomes compared to direct invasive mechanical ventilation (IMV) is unclear. METHODS:We performed a cohort study using a multicenter, nationally representative database including adults with CS who received NIV or IMV on the first hospital day. Patients were categorized as NIV only, direct IMV, or NIV before IMV. Inverse probability of treatment weighting balanced baseline characteristics. The primary outcome was in-hospital mortality. Sensitivity analyses excluded mechanical circulatory support and out-of-hospital cardiac arrest and additionally incorporated lactate adjustment and entropy weighting. RESULTS:Among 81,892 patients with CS, 13.7% received NIV alone, 81.9% direct IMV, and 4.4% NIV before IMV on the first day of admission. In-hospital mortality was 37.2%, 57.7%, and 52.1%, respectively. After adjustment, IMV and NIV before IMV had higher mortality than NIV (absolute risk difference 11.8%, 95% CI 10.4-13.3, and 12.9%, 95% CI 10.6-15.1; both p<0.001). Mortality did not differ between direct IMV and NIV before IMV (risk difference 1.0%, 95% CI -1.0-3.0; p=0.279). Notably, sensitivity analyses including lactate and when stratified by SCAI D shock showed higher mortality with NIV before IMV compared to direct IMV. CONCLUSIONS:Direct IMV and NIV before IMV were associated with worse outcomes than NIV alone. Results for direct IMV compared to NIV before IMV were not consistent between analyses and support the urgent need for a prospective study of respiratory support strategies.

Patients admitted to contemporary cardiac intensive care units (ICUs) increasingly present with complex low-flow states and multisystem organ dysfunction, particularly in the perioperative cardiac surgery setting. This article outlines a systematic, organ-based approach to optimizing extracardiac organ function in patients with shock, emphasizing respiratory, renal, vascular, neurologic, hematologic, gastrointestinal, and endocrine management. Key principles include understanding cardiopulmonary interactions, minimizing secondary organ injury, tailoring supportive therapies to physiologic profiles, and applying ICU best practices. Coordinated, multidisciplinary optimization of noncardiac organ systems is essential to improve surgical candidacy, reduce complications, and enhance outcomes in this high-risk population.

IMPORTANCE/OBJECTIVE:Since the cardiac intensive care unit (CICU) was first introduced into to the medical landscape, patient complexity, comorbidity, and illness severity have increased substantially over time. This evolution has required and informed the cultivation of new tools and an expanding skill set for those who deliver care in these units, and has paved the way for the emergence and growth of a distinct discipline-Critical Care Cardiology. With the genesis of this field and the need to care for comorbid and critically ill patients, numerous questions have been posed, including those related to optimal staffing models, appropriate training pathways, and the development of best practice principles to guide patient management. To address these and other challenges, to foster necessary collaborations, and to galvanize a maturing field, the Society of Critical Care Cardiology (SoCCC) was born. OBSERVATIONS/METHODS:SoCCC was created to provide an independent, yet complementary home for stakeholders within this rapidly growing discipline. Its mission is to address the unique needs and concerns of Critical Care Cardiology through an inclusive approach that prioritizes the development of early career faculty, actively engaging them to help to shape the field and to strengthen its unique practice environment - the CICU. While collaborations with larger professional societies remain essential, an independent subspecialty society like SoCCC intends to capitalize on the historical precedent and experiences shared by other successful organizations, while leveraging its nimble structure to advocate for and advance the needs of its constituency. CONCLUSIONS/RELEVANCE/CONCLUSIONS:While this document primarily details the history and rationale that led to the establishment of SoCCC, it also endeavors to be a practical blueprint to support future leaders who might be considering a new society for their own subspecialty.

BACKGROUND:Contemporary data characterizing older adults admitted to cardiac intensive care units (CICUs) across diverse indications are limited. OBJECTIVES/OBJECTIVE:The objective of the study was to describe the clinical characteristics, critical care therapies, and in-hospital outcomes of older patients admitted to the CICU compared with younger adults. METHODS:The Critical Care Cardiology Trials Network is a multicenter, international registry of CICUs. Between 2017 and 2024, participating centers contributed annual ≥2-month snapshots of consecutive medical CICU admissions. Admissions were categorized into 4 age groups: <65, 65-<75, 75-<85, and ≥85 years. Outcomes included CICU and in-hospital mortality and length of stay. Multivariable models adjusted for sex, illness severity (SOFA score), lactate, and kidney function. RESULTS:Among 35,265 admissions from 50 sites, 44%, 27%, 21%, and 9% were aged <65, 65-<75, 75-<85, and ≥85 years, respectively. Acute coronary syndrome was the most common admission diagnosis among all age groups. Patients aged ≥85 years had the lowest use of mechanical circulatory support (5.5%), which consisted exclusively of intra-aortic balloon pumps. Relative to patients <65 years, adjusted ORs of in-hospital mortality were 1.53 (1.40-1.67) for 65-<75 years, 1.83 (1.67-2.01) for 75-<85 years, and 1.95 (1.72-2.22) for ≥85 years. Among cardiac arrest patients the increase in mortality with age was steeper, reaching 3.09 (2.24-4.26) for patients ≥85 years. CONCLUSIONS:Patients ≥85 years in contemporary CICUs experience survival comparable to those aged 75-<85 years, except in the setting of cardiac arrest. These findings support consideration of factors beyond chronological age in CICU triage and treatment decisions.

BACKGROUND:Hospital ownership type may influence acute cardiovascular disease disparities that persist across the U.S. We examined associations between hospital ownership type and in-hospital and readmission outcomes for STEMI hospitalizations. METHODS:We performed a retrospective cohort study of hospitalizations for STEMI using the National Readmissions Database (2016-2022). Hospitals were categorized as nonprofit, for-profit, or public. Outcomes included in-hospital mortality and 90-day readmission for acute coronary syndrome, heart failure, cardiovascular, and all causes. Associations were assessed using multivariable logistic and Cox proportional hazards regression, adjusting for patient, hospitalization, and hospital-level characteristics. RESULTS:Of 610,427 STEMI hospitalizations, 460,451 (75.4%) were at nonprofit, 88,965 (14.6%) at for-profit, and 61,011 (10.0%) at public hospitals. Compared with nonprofit hospitals, for-profit hospitals (aOR 1.09, 95% CI 1.05-1.13) and public hospitals (aOR 1.17, 95% CI 1.12-1.22) were each associated with higher odds of in-hospital mortality. For-profit hospitals were associated with higher risk of 90-day readmission for acute coronary syndrome (aHR 1.15, 95% CI 1.10-1.21), heart failure (aHR 1.08, 95% CI 1.03-1.13), cardiovascular (aHR 1.08, 95% CI 1.05-1.12), and all causes (aHR 1.13, 95% CI 1.10-1.16) relative to nonprofit hospitals. Public hospitals were associated with higher risk of 90-day readmission for heart failure (aHR 1.08, 95% CI 1.02-1.13) relative to nonprofit hospitals. CONCLUSIONS:For-profit and public hospitals were associated with higher in-hospital mortality and 90-day readmission for various causes compared with nonprofit hospitals. These findings suggest that hospital-level factors may contribute to disparities in STEMI outcomes and warrant further investigation.

BACKGROUND/UNASSIGNED:The paucity of data to guide selection of specific vasoactive agents in patients with cardiogenic shock (CS) may lead to variability in practice patterns. The level of variability and specific factors that are associated with the use of vasoactive medications and inodilators have not been previously described. METHODS/UNASSIGNED:The CCCTN (Critical Care Cardiology Trials Network) is an international, multicenter network of cardiac intensive care units (CICUs) coordinated by the TIMI Study Group. This analysis included CICU admissions for CS from 2019 to 2023. Variation in the use of inodilator treatment (dobutamine/milrinone) was assessed with multivariable mixed-effects logistic modeling. RESULTS/UNASSIGNED:increase). No individual measurable institution-level factors (eg, transplant center) were associated with variability in inodilator use. In mixed-effects logistic modeling, 45.7% of variation in inodilator use was attributed to patient-level factors and 22.7% to the random effect of individual CICU centers. Similarly, 35.3% of variation in the use of dobutamine versus milrinone was attributed to patient-level factors and 32.6% to the random effect of individual CICU centers. CONCLUSIONS/UNASSIGNED:There is significant variation in vasoactive treatment and inodilator use in CS. Variation in inodilator use was associated with patient-level factors and with substantial individual CICU practice variation. Such variability underscores the need for additional high-quality evidence to guide vasoactive treatment strategies in CS.