Faculty Bibliography

Background: Hyperoxia produces reactive oxygen species, apoptosis, and vasoconstriction, and is associated with adverse outcomes in patients with heart failure and cardiac arrest. Our aim was to evaluate the association between hyperoxia and mortality in patients (pts) receiving positive pressure ventilation (PPV) in the cardiac intensive care unit (CICU).
Method(s): Patients admitted to our medical center CICU who received any PPV (invasive or non-invasive) from 2001 through 2012 were included. Hyperoxia was defined as time-weighted mean of PaO2 >120mmHg and non-hyperoxia as PaO2 <=120mmHg during CICU admission. Primary outcome was in-hospital mortality. Multivariable logistic regression was used to assess the association between hyperoxia and in-hospital mortality adjusted for age, female sex, Oxford Acute Severity of Illness Score, creatinine, lactate, pH, PaO2/FiO2 ratio, PCO2, PEEP, and estimated time spent on PEEP.
Result(s): Among 1493 patients, hyperoxia (median PaO2 147mmHg) during the CICU admission was observed in 702 (47.0%) pts. In-hospital mortality was 29.7% in the non-hyperoxia group and 33.9% in the hyperoxia group ((log rank test, p=0.0282, see figure). Using multivariable logistic regression, hyperoxia was independently associated with in-hospital mortality (OR 1.507, 95% CI 1.311-2.001, p=0.00508). Post-hoc analysis with PaO2 as a continuous variable was consistent with the primary analysis (OR 1.053 per 10mmHg increase in PaO2, 95% CI 1.024-1.082, p=0.0002).
Conclusion(s): In a large CICU cohort, hyperoxia was associated with increased mortality. Trials of titration of supplemental oxygen across the full spectrum of critically ill cardiac patients are warranted

Background: The use of positive end-expiratory pressure (PEEP) may influence cardiac output according to the patient's hemodynamics. However these effects have been only described in preclinical studies and very small patient series. Our aim was to evaluate the association between PEEP and clinical outcomes in patients undergoing mechanical ventilation (MV) who are also receiving invasive hemodynamic monitoring with a pulmonary artery catheter (PAC).
Method(s): We included patients admitted to the CICU with the diagnosis of cardiogenic shock (CS) receiving invasive MV during the first 48hrs of admission and who had a PAC in place. Patients were stratified according to their filling pressures as pulmonary artery diastolic pressure (PADP) above and below 20mmHg. Ventilatory parameters were measured and monitored every hour for the study period (48 hours). Outcomes of interest included lactate clearance, inotropic vasopressor score and survival and were compared according to the level of PEEP (above and below the median). Multivariate regression analysis was performed adjusting for age, sex, OASIS, PaO2, pH, peak lactate and presence of cardiac arrest Results: A total of 80 patients (age 65, IQR 54-79) with CS undergoing MV and PAC monitoring were included. The median PEEP in the low PADP was 7.7 (IQR 5.5-9.9, p =0.1) cmH2O and the median PEEP in the high PADP was 5.5 (IQR 5.0-6.6)cm H2O. In the low PADP group, unadjusted mortality was non statistically significantly higher in the group receiving PEEP below the median (33% vs 0%, p=0.1). In the high PADP group mortality was non-significantly higher in patients receiving PEEP above the median (57%) compared to the ones receiving PEEP below the median (33%, p =0.5). Multivariate regression demonstrated no difference in mortality according to PADP and PEEP level (OR 0.95 95% CI 0.60-1.50, p=0.83). In multivariate analysis there were no differences in lactate clearance or in the change o inotropic-vasopressor score (table).
Conclusion(s): In patients with cardiogenic shock undergoing MV and invasive hemodynamic monitoring, PEEP levels were not associated with differences in mortality, lactate clearance and inotropic/vasopressor score delta according to the left ventricular filling pressures as measured by pulmonary artery diastolic pressures. Further research in this area is need to better characterize the impact of PEEP in hemodynamics and clinical outcomes in patients with cardiogenic shock

Background: The use of positive end-expiratory pressure (PEEP) and different prescribed Tidal Volumes (TV) in patients with cardiovascular disease may affect clinical outcomes. However these effects may be dependent on the intrinsic cardiac function as well as the hemodynamic state of each patient. We aimed to analyze the interactions between PEEP and TV with survival in patients with cardiovascular disease according to their preload and afterload dependent status.
Method(s): We included patients admitted to the CICU receiving invasive MV during the first 48hrs of admission. Patients were stratified according as preload dependent (hypovolemia, right ventricular dysfunction, tamponade, hypertrophic obstructive cardiomyopathy or constriction), afterload dependent (left ventricular shock, elevated afterload) or neither preload/afterload dependence. Multivariate regression analysis was performed with PEEP, TV and covariates of survival, including age, sex, OASIS severity score, cardiac arrest, PaO2, PCO2 and plateau pressures.
Result(s): A total of 291 CICU patients (age 68, IQR 57-78) undergoing mechanical ventilation (MV) were included. There were no differences in survival according to PEEP level in patients with preload dependent status (OR 1.74 95% CI 0.85-3.55, p=0.1) or afterload dependent status (OR 1.02 95% CI 0.84-1.24, p=0.9). Similarly, TV was not associated with mortality in patients with preload dependent status (OR 0.61 95% CI 0.20-1.89, p=0.4) or afterload dependent status (OR 0.84 95% CI 0.56-1.24, p=0.3). In patients with neither preload or afterload dependent status PEEP or TV was not associated with increased mortality.
Conclusion(s): In patients with cardiovascular disease undergoing MV, there is no significant association between the level of PEEP or TV use and survival, even when stratifying patients according to their preload or afterload dependent status. Further research in this area is warranted to better understand the impact of positive pressure ventilation in patients with cardiovascular disease

Background: The use of mechanical ventilation (MV) in the cardiac intensive care unit (CICU) has become increasingly common. Low tidal volume (TV) ventilation has benefits in patients with ARDS, while positive endexpiratory pressure (PEEP) may impact hemodynamics. However the relationship between mechanical ventilation parameters and outcomes has not been systematically studied. We sought to analyze the interactions between tidal volume (TV) and PEEP with mortality.
Method(s): We included patients admitted to the CICU receiving invasive MV during the first 48hrs of admission. Patients were stratified into two groups of TV (low: <8ml/ Kg of ideal body weight), normal-high (8 ml/Kg of ideal body weight), low and high PEEP (above and below the median for the cohort). The primary outcome was all cause 30-day mortality Results: A total of 291 CICU patients (age 68, IQR 57- 78) were included. The median TV was 7.89 (IQR 7.18- 8.96) and median PEEP was 5.5 (IQR 5.00-7.71) and median plateau pressure was 19.7 (IQR 17-23) cmH2O. Mortality did not differ between low TV (30.2%) and normal-high (25.0%, p =0.8), or between PEEP (29.6% vs 254%, p=0.5, above and below the median respectively). After multivariable adjustment differences in mortality remained non-significant for TV groups (OR 0.84 95% CI 0.65-1.08) as well as for PEEP groups (OR 0.93 95% CI 0.87-1.12).
Conclusion(s): In a large cohort of patients undergoing MV in the CICU, the use of low TV ventilation is not associated with differences in mortality or MV duration. Similarly, with a median of 5cmH2O, there is no association between PEEP and mortality. Future prospective studies are required to evaluate the MV parameters in patients admitted to the CICU

Aims/UNASSIGNED:To define outcomes of patients with COVID-19 compared to patients without COVID-19 suffering in-hospital cardiac arrest (IHCA). Materials and methods/UNASSIGNED:We performed a single-center retrospective study of IHCA cases. Patients with COVID-19 were compared to consecutive patients without COVID-19 from the prior year. Return of spontaneous circulation (ROSC), 30-day survival, and cerebral performance category (CPC) at 30-days were assessed. Results/UNASSIGNED:Fifty-five patients with COVID-19 suffering IHCA were identified and compared to 55 consecutive IHCA patients in 2019. The COVID-19 cohort was more likely to require vasoactive agents (67.3% v 32.7%, p = 0.001), invasive mechanical ventilation (76.4% v 23.6%, p < 0.001), renal replacement therapy (18.2% v 3.6%, p = 0.029) and intensive care unit care (83.6% v 50.9%, p = 0.001) prior to IHCA. Patients with COVID-19 had shorter CPR duration (10 min v 22 min, p = 0.002). ROSC (38.2% v 49.1%, p = 0.336) and 30-day survival (20% v 32.7%, p = 0.194) did not differ. A 30-day cerebral performance category of 1 or 2 was more common among non-COVID patients (27.3% v 9.1%, p = 0.048). Conclusions/UNASSIGNED:Return of spontaneous circulation and 30-day survival were similar between IHCA patients with and without COVID-19. Compared to previously published data, we report greater ROSC and 30-day survival after IHCA in COVID-19.

Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.